Risk-Management Plan
Portfolio Project For your Portfolio Project you will construct a risk management plan based on a specific case, which is provided below. Using the case described, construct a risk management plan, including a root-cause analysis, and provide recommendation(s) for how this situation could be avoided—to safeguard future patients from having their safety compromised in a manner similar to what occurred in the case study. Be sure to identify all roles in your analysis. In addition to meeting the requirements described above, provide commentary that relates the case broadly to what you have learned throughout the course. Describe the roles played by quality and regulation to prevent unfortunate occurrences such as the situation described. Your final Portfolio Project should include a well-written paper of 7 pages and a PowerPoint presentation of 9 slides. The PowerPoint presentation should reflect the content of the paper, such as you would create to present the paper to your colleagues. Cite at least four (4) scholarly references in your portfolio. Your paper and PowerPoint presentation should be APA guidelines. The case is as follows: You are the Chief Risk Management Officer for a large city hospital. Your job is to create a risk-management plan based on the following: A patient presents in the emergency room with pain in the right side of her lower abdomen. Her last name is Jonesky. She has been ill and vomiting for two days. The patient is triaged and asked to take a seat until she can be seen. Additionally, the patient speaks only Russian, and her husband, who is the only family member with her, speaks limited English, with Russian being his primary language. Several hours have passed and the patient is still sitting in the emergency room, in extreme pain. The husband approaches the emergency room desk to try to communicate that his wife is worsening and in extreme pain. After several minutes of discourse, the patient is taken back into the emergency room to be seen. She is diagnosed with appendicitis and requires removal of her appendix. She is sent to a holding area outside of the operating room where she will wait to be taken into surgery. Upon her arrival, a nurse asks her name and due to the fact that the patient only speaks Russian, her name, Jonesky sounds to the nurse like Jones. Then anesthesia interviews the patient. Simultaneously, another emergency patient is brought into the holding area of the operating room. Her name is Samantha Jones. Samantha has fallen down icy steps and has broken her left ankle, which now needs to be repaired. This is a very busy night for the operating room. Additional staff members, who have already worked a full eight-hour shift, are called in to attend to this second case. Both patients are interviewed and taken into ORs for their procedures. Since it is late both surgeons do a time out, but not as judiciously as they would during the day. Staff members in attendance implicitly go along with the surgeons operating following time out that was not complete. As the procedure begins, the surgeon makes an incision into Mrs. Jonesky’s ankle and there is no sign of any broken bone. He realizes there is a problem. Additionally, the surgeon operating on Samantha Jones makes an incision and finds no sign of appendicitis. Both surgeons operated on wrong sites due to incorrect identification of the patient.
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