Case Study: Cultural Safety and Awareness in the Care of

assignment: Project Part III – Describing the Stakeholders and Resources for the QI Plan(USLO 2 & 4) FOR URINARY TRACT INFECTION Consider the root cause analysis performed and the results identified. Please review the table below provided by the Agency for Healthcare Research and Quality (2019): Table 1. Factors That May Lead to Latent Errors Type of Factor Example Institutional/regulatory A patient on anticoagulants received an intramuscular pneumococcal vaccination, resulting in a hematoma and prolonged hospitalization. The hospital was under regulatory pressure to improve its pneumococcal vaccination rates. Organizational/management A nurse detected a medication error, but the physician discouraged her from reporting it. Work environment Lacking the appropriate equipment for hysteroscopy, operating room staff improvised using equipment from other sets. During the procedure, the patient suffered an air embolism. Team environment A surgeon completed an operation despite being informed by a nurse and the anesthesiologist that the suction catheter tip was missing. The tip was subsequently found inside the patient, requiring reoperation. Staffing An overworked nurse mistakenly administered insulin instead of an antinausea medication, resulting in a hypoglycemic coma. Task-related An intern incorrectly calculated the equivalent dose of long-acting MS Contin for a patient who had been receiving Vicodin. The patient experienced an opiate overdose and aspiration pneumonia, resulting in a prolonged ICU course. Patient characteristics The parents of a young boy misread the instructions on a bottle of acetaminophen, causing their child to experience liver damage. Agency for Healthcare Research and Quality (AHRQ). (2019). Root cause analysis. They were retrieved from https://psnet.ahrq.gov/primer/root-cause-analysisLinks to an external site. In a 2-3-page paper, identify and describe the root cause analysis findings. Identify the stakeholders who would need to be involved in a quality improvement plan to address the reviewed clinical event. Note: When referring to an organization, remove all identifiers. From the table, identify which type of factor contributed to the occurrence of the clinical event. What role would each stakeholder play in implementing the quality improvement plan? What types of resources will the stakeholders need for the implementation of the quality improvement process to be successful? (Briefly address each of the following aspects in your paper.) Human Capital – Staff Time and Tools: Education materials Assessment tools Technology and support Financial – Budget cost and allocation Stakeholder Consensus

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