Organizational Systems-Wgu-Task 2

Organizational Systems-Wgu-Task 2
Organizational Systems and Quality Leadership Task 2 Jill Riccobono Western Governors
University Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis A root
cause analysis (RCA) looks at an event and considers what happened, why it happened what will be
done to prevent it from happening again and how will we know that the changes made will improve
the safety of the system. It takes into consideration causative factors, errors and hazards that led to a
sentinel event. In this case it was a patient's death. RCA should not look to place blame on people,
but rather processes that need to be improved. The first step in a RCA is to identify what happened.
In the scenario, presented in this task, the patient was ... Show more content on Helpwriting.net ...
Improvement Plan While there was a policy in place for conscious sedation, even good policies rely
on the vigilance of staff to adhere to them. Often times, working conditions allow for distractions,
and even the best of practitioners, with the best of intentions, make errors. There were several areas
presented in this scenario that require examination and improvement. First of all, in order to
improve patient safety, staffing levels need to be appropriate. In this case, as the patient load
increased, the staffing level did not. There was only one RN and on LPN on duty. As a proponent of
acuity based staffing, I would have a system in place that allowed for staff to be assigned based on a
patient acuity scoring system that would be implemented, that would staff the unit not only based on
the number of patients but also for the care required. In this case we have a patient that requires
constant monitoring, as well as another emergent respiratory distress patient. Had another nurse
been assigned to the unit, Nurse J, who was trained in conscious sedation, would have been able to
adhere to the existing policy and provide constant monitoring of Mr. B which most likely would
have avoided the outcome presented in this scenario. Again though, policies are only as good as
long as they are followed and staff is aware of them. More than just having a policy exist, there
needs to be double checks, check lists and ongoing education. In instances
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Organizational Systems and Quality Leadership
Organizational Systems and Quality Leadership Task 2 Mark Woodard Western Governors
University This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty
seven year old patient which presented to the emergency room with left leg pain. A root cause
analysis will be necessary in this case to investigate the causative factors which led to Mr. B's
sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in
the system will be identified. The Change theory will be used to develop an improvement plan that
will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B.
in the scenario. Root ... Show more content on Helpwriting.net ...
Improvement Plan An improvement plan using the change theory needs to be used to decrease the
likelihood of a reorrurance of the sentinel event that led to the death of Mr. B. in the scenario. The
change theory which would be best suited for this scenario would be The Model for Improvement.
The first part of the model has three fundamental questions. The first part is called, Aim: What are
we trying to accomplish? The second part is, Measures: How will we know a change is an
improvement? The third part is called, Changes: What change can we make that will result in
improvement? The second part of The Model for Improvement is the PDSA cycle. This is the testing
phase of the model. The acronym PDSA stands for Plan, Do, Study, and Act. This is a four step
process which is a simple way to test and make changes to the process. If The Model for
Improvement is applied to Mr. B's scenario, the aim of the improvement plan would be to make sure
that patients coming into the emergency room receive the appropriate dose of medications, that the
patients are monitored correctly, and that the staff is educated about proper medication
administration. The measures part, How will we know a change is an improvement, could be
answered by compiling data with the number of patients receiving hydromorphone in the emergency
room, what type of monitoring was used

Root Cause Analysis : Root Causes Analysis
ROOT CAUSE ANALYSIS
Root cause analysis process will utilize a systematic step–by–step approach to help identify all
causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to
understand how the event happened, why did it happen, and what can be done to prevent an event
from happening again. The first step, collect all necessary data associated with this event such as:
current policy and procedures, incident report, Mr. B's health history, environmental flowcharts,
dispensed medications, equipment and staffing factors relevant to the event. The process of
identifying causative factors can begin once all the data is collected. The goal, of a Root Cause
Analysis, is to identify interventions to prevent an event from reoccurring. Scenario: Mr. B, a 67–
year–old–man, came to the ER complaining of severe pain to his left hip and leg after falling over
his dog at home. Left leg appears shortened with swelling in his calf, bruised, and limited range of
motion.Mr. B has a history of impaired glucose tolerance and prostate cancer. Home medications
include atorvastatin and oxycodone for chronic back pain. Mr. B's labs, taken during a previous visit
with his primary care doctor, revealed elevated cholesterol and lipids. Several errors and hazards can
be identified as possible factors leading to the sentinel event. The ER appeared to be terribly
understaffed that day with only one ER physician, one RN, one LPN, and a secretary.

Research Paper On Failure Mode And Effect Analysis
5.0 Analysis and Methodology
5.1 Introduction
Failure mode and effects analysis (FMEA) is a specific safety tool for estimating the effect of
potential failure modes of assemblies, subsystems, components and functions. It is basically a
reliability safety method to recognize failure modes that would adversely disturb overall system
reliability analysis model. Failure mode and effects analysis has the proficiency to include failure
rates for each failure mode in order to accomplish a quantitative probabilistic analysis. Furthermore,
the FMEA can be extended to assess failure modes that may provide result in an undesired system
state and such as a system hazard, and thereby also be used for hazard analysis. Failure mode effect
and critical analysis (FMECA) is the detailed version of the Failure mode effect analysis (FMEA).
The FMEA method is an ordered bottom–up assessment technique that focuses on the function or
design of products and progressions in order to prioritize actions to moderate the risk of product or
process failures. ... Show more content on Helpwriting.net ...
Time and resources for a broad FMEA must be allotted through design and process improvement,
when design and process changes can most easily and economically be executed.
Failure causes: Why did the item failed?
Failure mode: Manner in which an item will fail.
Failure effect: Consequences of failure mode in terms of the operations, function or status of the
item.
Failure severity: Brief significance or grading of the failures modes effect on item operator; failure
mode effect severity as related to the defined boundaries of the analyzed system.
Failure criticality: Combination of the severity of an effect and the frequencies of its occurrence or
other attributes of a failure as a measure of the need for addressing and mitigation.
The FMEA analysis generally follows these steps:
Step1: Identify function
Step2: Identify Potential Failure

Process Improvement Plan
C. FMEA Failure modes and effects analysis (FMEA) is a systematic method to evaluate process
improvement plans. The purpose of the FMEA is to identify ways the plan might fail and what
impact the failure would have on the process. In the scenario of the task, the hospital had a moderate
sedation policy that was not followed and this resulted in the death of Mr. B. The process
improvement plan for this sentinel event involves a policy change to the moderate sedation policy
that includes the use of a checklist with a time–out component. The FMEA for this process
improvement plan will evaluate the use of the checklist since it contains all elements of the new
policy with–in the procedure checklist. A team will be chosen for the FMEA that ... Show more
content on Helpwriting.net ...
The Institute for Healthcare Improvement (IHI) website provides the resources the team needs to
test this process. The team knows the process will improve the safety of procedures, they are not
sure if the checklist fits well into the work flow of procedures and are unsure if the checklist will be
used as intended. A decision is made to use the Plan Do Study Act (PDSA) cycle to test the use of
the checklist. IHI's Model for Improvement focuses on three areas: aim, measures, and changes. The
aim or the goal is assuring the checklist is used for every procedure. The team decides to test in the
Interventional Radiology (IR) department to evaluate the use of the checklist. For one month IR will
use the checklist on all procedures requiring moderate sedation. After the trial, the staff in this
department will participate in an evaluation of their experiences with the checklist use. The team
will reconvene to address any issues found during the trial and make improvements as needed
(Lloyd, Murray &Provost,

Steps to Preparation for Failure Mode and Effects Analysis
Pre–Steps for preparing for FMEA.
Step 1: Select a process to evaluate with FMEA.
This is where a process to be evaluated with FMEA is carefully selected. When selecting a process,
special attention should be paid to the complexity of the process selected. A process that is not so
large and complex is preferred to a large and complex process. For example, select 'prevention of
pressure sore' instead of 'pressure sore' as a process to evaluate with FMEA. This is because
evaluating pressure will involve causes, prevention, treatment and risks factors.
Step 2: Recruit a multidisciplinary team.
The team should include everyone that is involved in the process. All team members do not
necessarily have to follow the process through the ... Show more content on Helpwriting.net ...
Failure mode is anything that could possibly go wrong, whether minor, major, and rare problems.
After identifying failure modes, the team will also identify possible causes for each failure mode
listed.
Step 5: For each failure mode, have the team assign a numeric value for likelihood of each
occurrence, likelihood of detection, and severity.
In this step, the team assigns numeric value known as the 'Risk Priority Number (RPN). The
purpose of assigning RPN is to help the team identify areas that are most likely to have problem so
that special attention could be given to such areas and improvement made proactively.
After successfully going through the 5th step, the team will carry out the 3 steps of FMEA which are
the likelihood of occurrence, likelihood of detection, severity, and assign score as appropriate. 3.
Occurrence: This is when the team consensually answered the question of, how likely is it that this
failure will occur? The ability to answer this question will help the team to determine what score to
assign to the step in question. The score will determine the level of priority to be given to that
particular step. Score is assigned between one and 10. One means "very unlikely to occur" while 10
mean "very likely to occur"
Detection: The team seeks to answer the question of "If this failure mode occurs, how likely is it
that it will be detected is? The team has to determine if

Development Of Generic Product And Approval
Generally, an ANDA sponsor of the topical dermatological product has to undergo multiple review
cycles with the FDA before the product gets approved and the sponsor has to wait for a longer time
mostly. Even though the ICH CTD, ICH Q8 describes the generation of product development report,
it is not still clear to ANDA sponsors how this actually applies. As a result, more internal meetings
and discussions between the sponsors and the FDA delays the product approval. One of the ways to
overcome these challenges is to have a product development report with verified and justified
specifications based on the QbD efforts which can help the Office of Generic Drugs (OGD) to be
efficient in understanding the developed generic product and approval ... Show more content on
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The foremost criteria in developing a generic topical dermatological product is to meet the
pharmaceutical and therapeutic equivalency of the RLD. A therapeutic equivalence is the one which
has the same clinical effect and safety profile as given in the label of the RLD and a pharmaceutical
equivalence is the one which contains identical amount of same active ingredient corresponding to
the same route of administration in the same dosage form with similar mechanism of release and
similar rate and extent of the absorption of the RLD. The current paradigm to get an approval by an
ANDA sponsor is by proving the therapeutic equivalence to the RLD by testing whereas the
proposed QbD approach requires the sponsors to meet the equivalence on the basis of defined
design targets. More specifically, a well–defined rational approach behind each testing is required
for proving the pharmaceutical equivalence and bioequivalence [18].
When talking about the design of equivalence of a generic dermatological topical product, the
criteria for Q1 and Q2. Additionally, in some cases, the Q3 criteria has to be satisfied in addition to
Q1 and Q2 Topical solutions can be stated as an example for Q3. The Q1, Q2 and Q3 may not be a
feasible option if the patent of the RLD is considerably protected. In such cases, the generic
manufacturer may be in a position to look for alternate

RTT1 Essay
RTT Task 2 The provided scenario gives an account of a busy emergency department with
competent staff, and the multiple errors that led up to the most severe error possible in healthcare,
unnecessary death of a patient. A root cause analysis (RCA) can be utilized to help understand the
systems at fault within the facility so that improvements can be determined and implemented to
prevent any future occurrences (Cherry, 456). RCAs focus on systems rather than blaming
individuals involved, therefore they are only appropriate in cases where there has been no willful
negligence or criminal acts (Huber & Ogrinc, 2014). The overall purpose of RCAs is to find out the
causes of the adverse event and determine how to keep similar errors from ... Show more content on
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These statements link the cause to its effects and then back to the main event that promoted the root
cause analysis (Huber & Ogrinc, 2014). Guidelines for writing causal statements include the need
for clarity in the relationship, statements should use neutral language and not imply blame, cause
should be given for any human error, and any violation of procedure should also have a preceding
cause (Huber & Ogrinc, 2014). Recommendations for interventions for change must next be made
for the process improvement process to be successful. Recommendations should meet the following
criteria; they should be clearly linked to the identified root causes, recommendations should address
all of the root causes, be designed to reduce the likelihood of reoccurrence and severity, and be clear
and concise (Huber & Ogrinc, 2014). The acronym SMART is also helpful: Specific, Measurable,
Achievable, Realistic, and Time measured. Once recommended changes are agreed upon the team
can use the concept of change theory to decrease the likelihood of recent sentinel events similar to
the example given. The IHI gives this definition on change theory "A change concept is a general
notion or approach to change that has been found to be useful in developing specific ideas for
changes that lead to improvement (IHI, 2004)." Recommended categories for change theory include
simplification, elimination of waste, improve workflow, manage time, and change the work

RISK MANAGEMENT Essays
RISK MANAGEMENT
Clinical risk is an avoidable increase in the probability of harm occurring to a patient
Clinical Risk Management (CRM) is an approach to improving the quality and safety of healthcare
by:


placing special emphasis on identifying circumstances that put patients at risk of harm acting to
prevent or control those risks
CRM helps the hospital: to maintain and improve quality of services improve patient safety reduce
frequency of litigation help maintain trust in profession prevent staff lose
Medical Error
It is the failure of a planned action to be completed as intended (i.e. error of execution e.g. error of
drug dose calculation) or the use of wrong plan to achieve an aim (I.e. error of planning e.g. wrong
lab result ... Show more content on Helpwriting.net ...
DOB and full name
Patient identifiers

Standardize patient identifiers among different departments e.g. name, birth, unique patient number
Have a protocol for comatose and mental patients e.g. tagging

Intervention

Even if a patient is familiar, check the details of the patient's identifier to ensure right patient
receives right care
Patients


Involve patients in the process of identification e.g. labelling sample in front of patient for
verification of name and DOB
SOP for Prevention of False Procedure
1.
2.
3.
4.
Patient identification
Marking of surgical site
Assignment to correct operating room
Team time out before incision (last call/ check before start)
RISK MANAGEMENT PROCESS
The process of risk management consists of 4 main steps:
Control risk Identify
Risk
Overcome risk Rate Risk
1.
Identifying the risk
Brainstorm on

Health Care and Emergency Transport Patient Essay
Root Cause Analysis
It is important to evaluate all aspects of the sentinel event as well as the events that led up to Mr. Bs
death. The questions that follow are pertinent because they set up a scenario with valid questions
that need to be answered. The goal is to identify errors and prevent reoccurrences incident in the
future. In the case study, it appears that a lack of protocols as well as a lack of communication
amongst staff members may have been contributing factors which led to death of a patient in the
emergency department.
In carrying out a root cause analysis, it is helpful to re–create the event with the staff members
integrated in the event. Members of ... Show more content on Helpwriting.net ...
Change Theory
According to (Mitchell,2013)change theories are similar problem–solving approaches to
implementing planned change. In the incident of Mr. B. following change theory is utilized
practicing Lappets theory.
Assessment
Nurse B makes a detailed assessment of the Mr. B that includes biographical details, relevant
clinical history, social details and medical observations. This phase is normally taken into
consideration throughout a patient's hospital stay.
Planning
Following assessment, the nurse b collaborates with the patient, significant other or family member
and multidisciplinary team wherever possible to determine how to address the needs of the patient.
Implementation
This phase relates to the nurse carrying out and documenting the care previously greed at the
planning stage. Post administration of sedations followed by a protocol which would closely
monitor patients vital signs. Nurse B continues to monitor the patient throughout the emergency
room visit shift. The vital signs are monitored every 15 minutes and documented. Parameters are set
instituting intervention if pulse oxygenation falls below 95%.

Evaluation
The evaluation phase all interdisciplinary team members and their part in the interaction of patient
care. Assessments graded for what worked well

Feasibility Of Preventive Maintenance On The Oil Pipelines
ABSTRACT Oil spills have devastating effects wherever it occurs like damage to aquatic, aerial and
terrestrial life. Most of NNPC's oil spillage is largely due to pipeline corrosion. This paper will
explore the feasibility of preventive maintenance on the oil pipelines which will aid in the
prevention and early detection of oil leakages. The major causes of pipeline spillages are corrosion,
stress, etc. Preventive maintenance practices on the oil pipelines consists of actions that will
improve the conditions of the pipeline systems for optimized performance and aversion of unwanted
system failure. A preventive maintenance system will be developed using the FMEA approach as
methodology. Keywords: Oil spillage, NNPC, pipelines, preventive ... Show more content on
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Consistent oil spills from these pipelines constitute health hazards. Problem statement Currently
majority of NNPC's pipelines are poorly maintained and this is causing oil spillage as the pipelines
tend to rupture or leak when oil is being transported to the refineries. A ruptured or leaking pipeline
is very hazardous to the environment and leads to production loss for NNPC. From the most current
data released, NNPC lose 600,000 barrels of crude oil, which is about 28% of the 2.1 million barrels
produced daily with total worth of about $160 million annually (NNPC annual report). In a study
conducted on productivity of industries in Nigeria which also applies to NNPC, it was identified that
most of the causes of low productivity were due to lack of manager's unwillingness to maintain the
system effectively (Nwachukwu, 2006). Poorly maintained operation management activities result
in low production quality and quantity, low market share and low growth rate. In the case of
NNPC's pipelines, apart from low productivity, oil is spilled which has disastrous effects on the
community. Thesis statement The emphasis of this praxis will be development of a preventive
maintenance system for NNPC which will drastically reduce or eliminate oil spillage from the
pipelines, reduce adverse consequences of lack of a maintenance system like frequent oil spillage,
identify optimal maintenance practices that will prevent future leakages of oil pipelines and
implementation of standard

Wgu Organizational Trends Essay
Organizational Leadership WGU A. A complete root cause analysis (RCA) that incorporates the
causative factors, errors, and hazards that led to the patient's outcome or sentinel event. Sentinel
event refers to the occurrence of serious physical illness or death or psychological injury or even
those incidences whose recurrence involves risks with adverse and serious outcomes. It may result
into deaths that are not anticipated or permanent loss of a major function that is not associated with
patient's natural cause of illness or condition (Lewis et al, 2014). The causative factors of Mr. B's
demise, according to the scenario described are that Mr. B was not put on oxygen or an EKG
monitor ... Show more content on Helpwriting.net ...
A breakdown of the causative factors that led to Mr. B's demise is as follows: Failure of O2 and
being placed on the EKG monitor Lack of continual monitoring post sedation by staff member Lack
of enough trained staff in conscious sedation available at the time of the procedure Resetting of
alarms without action Not enough staff present in the ER during high patient volume and acuity B.
Discussion on the process improvement plan that is likely to decrease or eliminate the reoccurrence
of the outcome or scenario. The process is an action plan that tends to illuminate on the strategies to
be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B's
scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as
timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the
root cause analysis (RCA) findings conducted above should help in the determination of the
appropriate action plan. The appropriate improvement plan in this scenario should encompass the
reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing
mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the
types of patients that were in the ER at the time. When

Failure Mode Effect and Criticality Analysis of Stub Axle...
Failure Mode Effect and Criticality Analysis of
Stub axle subassembly
1. Introduction: FMECA is a methodology to identify and analyse predicted failure modes of
various parts within the assembly or system. It is a technique to resolve potential problems in a
system before they occur. It is most widely used reliability analysis technique performed between
the conceptual and initial stage of the detailed design phase of the system in order to assure that all
the potential failures have been considered and the proper provisions have been made to eliminate
these failures. [1] (Ref. system reliability theory,2nd edition, Marvin Rausand) this technique can
assist in selecting alternative concept for the same system and also provide ... Show more content on
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The outer racer of the bearing is fastening into the boss. The whole subassembly is then attached
with the steering arm, stub axle by means of welded joints and the plate welded to the chassis by
means of Rod end bearing(2). The steering arm is joined with the steering rod by swivel joint as
shown in the fig1. By going through the force diagram2 of the system below, the number of
components those are highly stressed and because of which may fail or lack in desired performance
is four.
i. Stub axle: stub axle whose main function is to be a hostage of the wheel may be deformed due to
high fatigue stress induced due to the repetitive compressive load on upper edge and tensile on
lower edge as many times as the wheel experiences high impact load in upward direction. And the
result is the difficulty while cornering. Even though the probability of failure of stub axle is higher
due to impact failure of weld joints. Which may cause the serious safety effect.
ii. Hose and Bearing subassembly: As its main function is to reduce the friction, and providing
bearing support, its conceivable failure is detected by testing during maintenance. the probability of
failure is either wearing off the rolling element, or misalignment of bearing which is a result of
failure of bearing spacer. The system effect due to this is difficulty in cornering the vehicle, harsh

Failure Modes And Effects Analysis
Some key differences concerning the failure modes and effects analysis (FMEA) and a root cause
analysis (RCA) are clarified. Failure mode and effects analysis is conducted prior to any event.
FMEA is a preventive action used to help prevent a failure. The FMEA committee consists of about
three to four members who all are experts in the designated subject. Through FMEA the committee
helps develop action plans to reduce the risk of failure (Quality–One, 2011). RCA is an investigation
that occurs after a sentinel event that is unexpected. Through the RCA you are looking to find out
why did an event occur or not occur, how the event happened, and how to prevent additional events
for occurring (VA National Center for Patient Safety, 2015).

Summer Internship Report on Madura Garments
Project Report On Improving Service Level for Institutional Sales SUBMITTED FOR THE
PARTIAL FULFILMENT OF POST GRADUATE DIPLOMA IN INDUSTRIAL MANAGEMENT
(PGDIM) By Puneet Verma Roll No. 105 PGDIM – 18 Under the guidance of [pic] National
Institute of Industrial Engineering (NITIE), Vihar Lake, P.O. NITIE, Mumbai 400 087 Date of
Submission: _ _ _ _ _ _ _ Certificate of Supervision This is to certify that Puneet Verma, student of
PGDIM, Batch No. 18 has successfully completed the project titled – "Improving Service Level for
Institutional Sales", under the guidance of Mrs. ... Show more content on Helpwriting.net ...
Methodology...........................................................................................................24 5.1: Understand
the current market and business scenario......................................25 5.1.1: Market Scenario:
......................................................................................25 5.1.2: Agent Performance:
................................................................................. 29 5.1.3: Business processes:
................................................................................. 30 5.1.4: Key Points:
.............................................................................................. 35 5.2: Ascertain the current service
level of the system............................................ 36 5.3: Identifying and Defining
Problems................................................................. 37 5.3.1: Fishbone Diagram:
................................................................................. 37 5.3.2: Cause and Effect Matrix:
........................................................................ 38 5.3.3: Failure Mode Effect
Analysis:..................................................................39 5.3.4: Principal

Application Of Ich Q9 As A Systemic Process For The...
Introduction
ICH Q9 (Quality Risk Management–QRM) is a systemic process for the assessment, control,
communication and risk review to the quality of the medicinal product. Application of QRM can be
done by both proactively and retrospectively. It was adopted by European Union and PIC/S‡ in
Annex 20 of EU and PIC/S GMP guides. In pharmaceutical industry, Quality System is important
criteria and QRM is a valuable component of an effective quality system.
The QRM should ensure that the evaluation of the quality risk is based on some criteria like
knowledge about science, experience with the different process and ultimately links to the
protection of patient. It also ensures the effort level, formality and documentation of the QRM
process is appropriate with the level of risk. Product quality should be maintained throughout the
product lifecycle such that the attributes as it is important to the quality of the drug product which
remain consistent with those used in the clinical studies. It can further ensure the quality of drug
product to the patient by providing a proactive means to identify and control potential quality issues
during development and manufacturing. It can facilitate better and more informed decisions, and
can beneficially affect the extent and level of direct regulatory oversight.
Guidance to ICH Q9 provides principles and tools for QRM which can be applied to different
aspects of pharmaceutical quality includes development, manufacturing, inspection and

A Root Cause Analysis ( Rca )
A.
Root Cause Analysis
A root cause analysis (RCA) must be conducted when a sentinel event occurs in order to identify
where the systems and pro cesses involved failed and how these systems may be improved to
eliminate or reduce the risk for a reoccurring event of this type
(Cherry
, 2011
)
.
The
first step in conducting a root cause analysis is to form a committee of individuals that are from
different levels of t he organization to review the failures of the system and processes that are
associated to the event. This allows the committee to implement appropriate changes if necessary to
the system and process to reduce the risk of a future ev ent of this nature havi ng .
Based on the scenario provided
Mr. B arrived at the hospital with a ... Show more content on Helpwriting.net ...
ORGANIZATIONAL SYSTE
MS & QUALITY LEADERS
HIP
3
A1. Errors or Hazards
In the scenario provided the following are errors that led to the un fortunate outcome.
T
h e l ack of proper staffing and a radiology study to confirm that Mr. B did not have any fractures
prior to the reduction procedure may have contributed to his death
.
A s Mr. B could have had internal bleeding from a fractured pelvis or femur that w ent undetected
.
The ED physician's medication dosages were unsafe and the re
–
administration times increase d the risk of harm to the Mr. B.
The lack of knowledge or communication betwee n Nurse J and the ED physician in regard to the
medication dosages and re
–
administration times led to the over sedation of Mr. B

.
The scenario d oes not confirm that
Nurse J or th e
ED
physician had successfully completed the training module for conscious sedation required by the
hospital where they worked
.
Regardless,
Nurse J and the ED physician failed to follo w the policy in regard to a dministeri ng c onscious
sedation to Mr. B
.
Nurse J and the LPN failed to call for a respiratory therapist to be present d uring a conscious s
edation procedure.
; n or did anyone in the emergency

Occupational Accidents And Injuries Caused By The...
Occupational fatalities and injuries caused by the operation of lifting machinery pose a serious
public problem in the. Crane activities are responsible for 4% of the reported accidents. Several
studies have been performed examining the causes of injuries and deaths from cranes.
For any industry to be successful it should meet not only the production requirements, but also
maintain the highest safety standards for all concerned. The industry has to identify the hazards,
assess the associated risks and provide proper control measures to tolerable level on a continuous
basis. Unsafe conditions and practices in industry lead to a number of accidents and causes loss and
injury to human lives, damages the property, interrupt production etc.
Hazard identification involves identification of undesirable events that leads to a hazard, the
analysis of hazard mechanism by which this undesirable event could occur and usually the
estimation of extent, magnitude and likelihood of harmful effects. People want both–dead and live
resources, health and wealth and industrialization and employment–but nobody wants accidents.
This becomes possible if and only if the concept of safety is understood and followed.
To maintain safety of people and to follow safe work practice in safe working condition is the only
way to prevent and control the hazard of environment and (including industry). There for it is most
important to realize study and apply the concept of safety in every walk of life,

Mr B Root Cause
RTT1 Organizational Systems Task 2 The purpose of this paper is to analyze the unfortunate
sentinel event of Mr. B, a sixty–seven–year–old patient presenting with severe left leg pain at the
emergency room. A root cause analysis is necessary to investigate the causative factors that led to
the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change
theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a
reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA)
will be used to project the likelihood that the suggested improvement plan would not fail. Lastly,
key roles nurses would play in improving the quality of care ... Show more content on
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B's tolerance to opiates not considered, Mr. B.'s clinical situation not considered (i.e., Mr. B's age
and renal function), and knowledge deficit of opiates. Drilling down the data to identify the root
cause of Mr. B's death is the fifth step in conducting a RCA on Mr. B's sentinel event. Upon
analyzing the data, causative factors, and events leading to Mr. B's sentinel event, the RCA team
determined that the root cause of Mr. B's death is a medication error. Mr. B was given an overdose
of hydromorphone. The final step in a root cause analysis is to implement changes that will mitigate
the root cause. Changes include educating the nursing staff about hydromorphone, such as side
effects and adverse reactions, A1. Errors or Hazards There are errors and hazards in care that
occurred in the Mr. B scenario. One error was the emergency room physician's failure to recognize
the signs and symptoms of deep vein thrombosis (DVT) that Mr. B was presenting. If not treated
early, a DVT can become a pulmonary embolism, a fatal condition that Mr. B unfortunately
developed. Another error in care that happened in the Mr. B scenario is the nurses' failure to monitor
Mr. B's ECG and respirations. Early detection of critical ECG and respiratory changes could have
initiated medical interventions that would have saved Mr. B's life. One hazard is the emergency
room nurses' heavy patient load at the time of Mr. B's sentinel event. Another hazard is having a
licensed

The Effects Of Risk Management On Health Care Organizations
In the context of risk management, there are several ways that Failure Mode and Effects Analysis
can be used to improve processes in health care organizations. According to Stanley Davis and
colleagues, documenting and analyzing potential risks proactively is essential for improving patient
safety (Davis, et al., n.d.). The article states that Failure Mode and Effects Analysis (FMEA) is used
prospectively to identify the possible system failures, and to fix the problems to make the system
more robust before an adverse event actually occurs (Davis, et al., n.d.). In a study conducted by G
Bonfant and colleagues (2010), FMEA was used for chronic hemodialysis outpatients. The authors
recorded phases and activities, listed activity related failure modes and effects, described control
measures, assigned severity, occurrence and detection scores for each failure mode and calculated
the risk priority numbers (RPNs) by multiplying the 3 scores (Bonfant, et al., 2010). The authors
(2010) also analyzed failure mode causes, made recommendations, and planned new control
measures. Their results showed that the failure modes with the highest RPN was from
communication, and organizing problems (Bonfant, et al., 2010). They (2010) created two tools to
fix the communication flow, including dialysis agenda software, and nursing datasheets. In addition,
the authors scheduled nephrological examinations, and changed medical and nursing organization,
and this resulted in a decrease in RPN value

Theoretical Underpinning Of Change
Electronic documentation provides clarity in orders for tests and medications as well as the ability to
identify and properly bill for services rendered. The change to electronic documentation from paper
charting is not an easy task, but one that is needed to remain current with the needs of healthcare,
and will lead to improved medical records. This paper will discuss the background of electronic
medical records (EMR) use at Eglin Airforce Base (AFB) using dimensions defined by the Institute
of Medicine (IOM), review a theoretical underpinning of change, illustrate an improvement tool,
describe a model for quality improvement (QI), examine the resources required for change, and
propose evaluation methods of quality measures. Background of ... Show more content on
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Run charts are extremely effective as they depict the effects of change over time and shows highs
and lows in the transition process ("Run charts", 2004). Run charts also have the ability to identify
areas of revision as the time is an axis and the goal rate is an axis and the ability to see change
points marked on the graph shows the points of needed improvement and the results of any
implemented change. A run chart may show qualitative values with a review of staff usage
identifying the staff's viewpoints and comfort with the new system. Another valuable evaluation
method is the use of a histogram. A histogram enables a team to recognize and analyze patterns in
data ("Histogram", 2004) These variations in patterns could depict time of day variances, or
provider type variance in EMR use, or case load variances in the ER that are not apparent simply by
looking at a table format of data. Both evaluation methods illustrate different values which are
essential to measure the success of the QI project. The histogram would identify quantitative values,
the quantities of variances based on the times or providers in EMR

Case Study: Failure Mode And Effect Analysis
(d) Make recommendations for the company to overcome the problems identified and evaluated.
Raw material risk
The most common technique to mitigate the raw material risk is developing a risk assessment
program. The risk assessment process is prioritizing materials for assessment, determine evaluation
criteria through FMEA framework, assess types of risk and set goals for tolerable risk levels. Nestle
Berhad can decide the scope, assemble a team and create a plan to identify the list of materials for
analysis. Besides, Nestle Berhad should involve the appropriate people for purchasing, materials
planning or management, process development, quality and manufacturing. Furthermore, Failure
Mode and Effect Analysis (FMEA) framework is a rigorous ... Show more content on
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IOI Corporation Berhad can use hedging in order to mitigate the foreign exchange risk. IOI can
hedge the foreign exchange through spot contract, forwards or future contract, option contract and
swap. The spot contracts fix exchange rate against fluctuations and the company might not be able
to get benefit but also no get loss in spot contract even loss also just lose a little money. Besides that,
IOI can offset foreign currency holdings with futures and forward contracts. A forward contract is a
transaction in which the delivery of the commodity is postponed until the contract has been made.
The delivery is often in the future, however, the price is well determined in advance. Hedging is the
act of taking an offsetting position in a related security. A perfect hedge can reduce risk to nothing
except the cost of the hedge. Furthermore, IOI can use option contract to reduce foreign exchange
risks. Just like stocks, currencies have calls and puts that allow buyers to buy or sell the financial
asset at a predetermined price during a certain period of time or on a exercise date. Lastly, IOI can
use swap to to mitigate the foreign exchange risk. The company could swap to take advantage of the
lower

Essay RTT Role of Organizations
Running Head: ORGANIZATIONAL SYSTEMS 1
ORGANIZATIONAL SYSTEMS
ORGANIZATIONAL SYSTEMS 2
Organizational Systems
This paper is the analysis of the avoidable sentinel event of Mr. B, a sixty–seven year old patient
who was admitted to the emergency room with left leg and hip pain following a fall. A root cause
analysis will help identify key elements which led to the unfortunate event. A plan of action to
develop a change theory will help formulate an improvement plan to prevent future occurences like
that of Mr. B. A failure ... Show more content on Helpwriting.net ...
The nurse and ER doctor failed to recognize how the medications react by relaxing the skeletal
muscles, compromising Mr. B's lung expansion. Since Mr. B could not walk around to expand his
lungs, he could have benefited from bronchodilator treatments or supplemental oxygen. When the
LPN addressed the low oxygen alarm by resetting the alarm and leaving the room, she neglected to
assess Mr. B and failed to perform her duties as a nurse.
ORGANIZATIONAL SYSTEMS 3
Change Theory The employees, such as Nurse J and the LPN need to be advised that they did not
adequatley carefor Mr B by not assessing him properly upon his arrival, and not calling the
respiratory department for additional help when his respiratory status was in question. Informing the
LPN that she failed to assess and care for her patient when the low oxygen alarm was set off would
be unacceptable in the employee's performance. Clear warnings to correct their performance
deficiencies will result in adverse consequences. Identifying the problem or the skill the employee
lacks in by being specific will help address the problem. An established expectation would be
defined in the area of performance that needs to be changed with a clear list in writing. A deadline
that is reasonable between the supervisor and the employee needs to written and agreed upon.
Resources that the employee may need such as

Public Relations Personnel : Graphic Artists And Designers
Newspapers 01–June–2017 to 31–Aug– 2017 3 months 6 times over a period of 3 months Public
relations personnel, Copywriter, Graphic artists and designers Public relations personnel: These
personnel using the right tools and activities, can promote positive attitudes and behaviors towards
the business that will help convert interested consumers into customers. Copywriters: The
copywriter writes text or script for an advertisement, based largely on information obtained from the
client, who are responsible for visual aspects of the advertisement and, particularly in the case of
print work, may oversee production. Graphic artists and designers: Ones who are to troubleshoot
typing mistakes or incorrect information ... Show more content on Helpwriting.net ...
Longer and more response forms: It 's a two–way flow of information, interactivity. These feedback
forms help in keeping customers satisfied and in turn helps them to pass the word along. Further
follow–ups help not only in determining the prospects future needs but also makes long–lasting
customers. Performance Gap of the Action Plan How You Would Address These Issues to Facilitate
the Continuous Improvement to Meet the Designed Targets External Interference Understanding the
feelings, thoughts, and motives of customers is all the more important, which could minimize most
of the problems. In addition, external uncontrollable factors to be analyzed and taken proper care of
to overcome the same. Productivity Below Budget At first, building a money step into planning may
feel like slowing the business down. Being realistic about the costs of all great plans can, in the
beginning, put a damper on how we feel about the upcoming year. However, as we add budgeting to
our planning process on an ongoing basis, we will discover a balance between productivity and
money that fits in and the tolerance for financial risks. This balance will give a sense of financial
security so that we can take calculated risks, grow our business, and have the impact we want.
Quality, OHS or Environmental Failure The Failure Modes and Effects Analysis (FMEA) is
employed to analyse risk management for OHS, environment and quality management. FMEA is

Report : ' Driving Out Fear '
1)
a) To me, Dr. Deming's 8th point "Driving Out Fear," means several different aspects that helps a
company reach a Total Quality Management position. When employees have fear, it creates an
environment that does not allow everyone to work effectively. By eliminating fear, the workers are
able to build trust with each other, have less hesitation when change is scheduled to occur, and also
achieve better quality by allowing workers to feel secure in their position. Employees will more
comfortable and safe in their position, allowing them to work more efficiently. This sense of relief is
crucial, it now allows the employee to fully focus on their respective tasks rather and no longer have
second thoughts about communicating with team. Instead they understand that the people they work
for as well as work with have confidence in them and they are all part of the team. This encourages
them to have a higher sense of empowerment, and share any and all ideas they believe may help the
company operate better.
b) Although there are numerous tools that apply to driving out fear in an organization, I believe the
two most effective ones rely on Project Management and CMM. Project Management stresses the
importance of reaching your projects requirements by implementing your tools, skills, and
knowledge to the project activities. Among the many benefits of Project Management is that it
increases participant's communications as well as clarifies project goals and project scope.
Developing

The Importance Of Error Analysis And Failure Mode Effects...
Introduction
In every work environment, there are various continuous quality initiatives in place to improve
organization's product or service quality. For instance, in the United States, many patients have been
losing lives due to serious and avoidable medical errors or safety events (Muething et al., 2012). For
this reason, it is crucial to understand how these avertable medical errors or safety events can be
prevented or eliminated. There are factors involved in the process of analyzing particular errors in
an organization. This paper focuses on two processes of error analysis (Root Cause Analysis (RCA)
and Failure Mode Effects Analysis (FMEA)) to address unnecessary medical errors (Serious Safety
Events (SSE)). SSE in a healthcare ... Show more content on Helpwriting.net ...
These encounters make it cumbersome to classify alleviate primary causes of harm. Therefore, it
affects the ability of the society to identify and prove the efficacy of patient safety risk management
solutions that decrease medical errors and preventable serious safety events.
Measures push for improvement, inform patients and effect payment. Both public and private payers
apply measures to make a decision on the health providers they should contract and to enhance
improvements in healthcare. Hence, describing, categorizing and emphasizing on harm prevention is
critical for any practical risk management program.
To prevent or eliminate numerous deaths related medical errors. American Society for Healthcare
Risk Management has come up with Getting to Zero. Getting to Zero is a Serious Safety Events
initiative, which emphasizes on event investigation stages. The core part of the investigation process
is to establish harm–score. This always prompts an organizational response and risk management.
Therefore, without proper and accurate harm–score examination, the chances for applying
operational response may be wanting.
American Society for Healthcare Risk Management developed Harm Classification Tool to help risk
managers and health care leaders to group an event when deviation happens. Additionally, the tool
aids them to ascertain what actions are suitable for a particular event. The tool supports the
American Society

Evaluation And Implementation Of Abc Hospital
ABC hospital has/had been having numerous issues within the hospital along with the issues related
to the hospitals' processes. Some of the hospitals situations included: excessive wait times,
excessive delays in care, elopements, patient falls, excessive costs, decrease patient satisfaction, and
not being able to prioritize their patients appropriately nor accessing the situation effectively for the
patients needing services (Nash, Grandon, Grandon, & Goldfarb, 2006). After ABC's hospital
executives evaluated the situations that the organization has been facing, they embarked on a nine
month journey; in order to investigate completely all the situations that arose as well as developed
action plans and changes in the hospital to alleviate these situations. The following report will
include detailed information regarding the solutions and plans the hospital initiated within the
organization to resolve these problems. The report will also include information related to three
types of quality or risk management techniques or tools the hospital could have used during their
evaluation and implementation phases during the project. An organization has the availability to
utilize various tools, concepts, benchmarking measures, reporting measures, etc... in order to
improve the overall sustainability of the organization and improve the effects of their actions to
increase quality and efficiencies. No tool has been designed to be the only tool as the best approach
when addressing

Crankshaft Executive Summary
EXECUTIVE SUMMARY : This project is based on FMEA, an organized approach that guarantees
potential process failure modes and their related causes have been considered and tended to in the
outline of the procedure. in this report we considered one product to study and take all the aspects
into consideration to address main cause of failure of the product and its effects, after it moving
further to the improvement system and then show some results based on research material. At the
end, reveal a conclusion based on whole report outputs.
PRODUCT : CRANKSHAFT
PROJECT DETAILS : Project in view of crankshaft automobiles FMEA demonstrate in light of
value. Breaking down potential reasons for impact on crankshaft . This is based on information got
utilizing procedures in view of oral meetings and survey organization on mechanical disappointment
of crankshafts from the specialists working in the ranges of car support and crankshafts
reconditioning to enhance yields of the projects.
PROJECT METHODOLOGY : Main causes of crankshaft failure
SCOPE :
''Improving the efficiency of automobiles by investigating the procedure FMEA. Decreasing the
disappointment happens amid assembling process and expanding the efficiency in the firm''.
MARKET SEGMENT FOR CRANKSHAFT :
The report portions the Automotive Crankshaft showcase as:
Car Crankshaft Market: By Vehicle
– Heavy Commercial Vehicle–Light Commercial Vehicle–Passenger Vehicle–SUV–MUV–Others
Car Lighting System Market: By Crankshaft Type
– Flat Plane–Cross Plane
Car Lighting System Market: By Crankshaft Material
– Cast Iron–Forged Steel–Others.
Team members for FMEA :
Process Engineer – Generally the Team Leader
Production Operators
Industrial Engineer
Design Engineer
Quality Engineer
Reliability Engineer
Tooling Engineer
Maintenance Engineer
Project Manager

Others including Sales, QA/QC, Operations
FMEA table analysis from previous report study :
–Crankshaft failures data from maintenance experts (2007–2013). k Brand/category k of vehicle
specialized on Maintenance workshop Years i Serviced vehicles per year, Si No. of failure per year,
fi Identified causes of failure Proposed remedy
1 Private cars Workshop (A) 2007 1 49 12 OL, OD, TBM, PR,

Risk Analysis Is Essential For Any Company Regardless Of...
Risk analysis is essential for any company regardless of what it may specialize in. However, risk
analysis models must be constantly updated. Many older methodologies just cannot meet the
modern standards because of factors being constantly introduced in the business environment as
business and the world adapt to new developments. However, modern theories in cognitive
psychology indicate that there are two fundamental ways humans comprehend and rationalize risk.
These concepts reach into all forms of risk analysis. In relation to security risk analysis these are
often referred to as Quantitative and Qualitative risk analysis. Quantitative risk analysis uses
algorithms, probability calculus, formal math based logic, and risk assessment to ... Show more
content on Helpwriting.net ...
The challenge is to correctly balance the two.
Quantitative risk analysis attempts to calculate the probability of an event occurring along with what
will likely be lost. These calculations are called typically designated with names like the "Annual
Loss Expectancy" (ALE) or "Estimated Annual Cost" (EAC). (Osman) These numbers are figured
by multiplying the potential loss by the probability of it occurring. Theoretically, it is possible to
rank events based on an ALE or EAC score; however, in practice using just this type of risk analysis
has several drawbacks mostly related to inaccuracy and unreliability of this data. Often times risks
are often interrelated as the existence, and then occurrence, of a risk often times snowballs causing a
seemingly low risk situation to become either much more likely to occur or more damaging.
Qualitative Risk Analysis is much more widely used. In this form of risk analysis probability of risk
occurring is not taken into consideration. Three interrelated variables are of taken into consideration
when using formal Qualitative Risk Analysis to analysis security risk: threats, vulnerabilities and
controls. (Osman) Threats are potential variables that could cause loss in some way. These exist in
every system. For instance, in information systems threats may be hackers or even disgruntled
employees. Vulnerabilities make a system more likely to be attacked and for that attack to be more
successful. A recent

Failureure Mode And Effect Analysis: Failure Mode And...
Abstract–Failure mode and effects analysis (FMEA) is a failure anticipation and risk assessment
framework that alleviates potential failures in systems and is being used in many industries. The
main goal of FMEA is to identify all failures and their modes in a system, assesses their effect and
recommends corrective actions. It not only improves reliability and safety of complex systems but
provides information for taking risk management actions. The conventional FMEA quantifies a risk
associated with a failure by assigning Risk priority number (RPN). RPN is based on the product of
occurrence (O), severity (S) and detection (D). This framework of quantifying risk has been
criticized much in academia. Many advanced techniques are being used ... Show more content on
Helpwriting.net ...
Risk is an uncertain, unreliable state or condition that, if it occurs, has an effect on project goals.
Risk management is an indispensable part of successful project management. Risk management is
the art and science of anticipating and planning for future uncertain events and the objective is to
understand and mitigate or control risks. Failure mode effect analysis is a structured analysis
technique which defines, identifies and rejects probable failures, disasters, and errors at component,
subsystem and system levels [1]. The main motto behind FMEA is to identify the likely failure
modes, establish a cause– effect relationship with the failure mode, and enumerate the
accompanying risk. The analysis provides a tool to correct the most prominent failure modes that
effect the system most.[1.1] FMEA is being used in a wide range of industries like automation
,aviation ,aerospace, electronics, nuclear, mechanical, and chemical industries.
A failure mode is the fashion in which a component, subsystem, system, process, etc. could possibly
fail to perform the intended function. A failure cause is a design weakness which leads to a failure.
Each failure mode has an associated effect. A failure effect is the consequence of a failure mode on
the function of the product or process as perceived by the customer.
Conventional way of analyzing risk in FMEA is based on developing

The General Purpose Of The Failure Mode And Effects...
C. Explain the general purpose of the failure mode and effects analysis (FMEA) process.
Failure Modes and Effects Analysis (FMEA) is approach to examine possible problems early on in
the development of a process to evaluate how the process might fail. To evaluate prior to the process
being implemented it will make it easier to take actions to overcome issues and change them.
(Failure Modes and Effects Analysis (FMEA) Tool, 2017)
C1. Describe the seven steps of the FMEA process.
Step 1: "Select a process to evaluate with FMEA" (Failure Modes and Effects Analysis (FMEA)
Tool, 2017). In the first step will define what is to be evaluated and with the process that will be
used.
Step 2: "Recruit a multidisciplinary team" (Failure Modes and Effects Analysis (FMEA) Tool,
2017). This step involves gating of a team with diverse backgrounds and with expertise in the area
to be evaluated. A team advisor must also be appointed.
Step 3: "Have a meeting to list all of the steps in the process" (Failure Modes and Effects Analysis
(FMEA) Tool, 2017) Design and confirm the diagram that will be used. Number the steps that were
identified in the diagram.
Step 4: "Have the team list failure modes and causes" (Failure Modes and Effects Analysis (FMEA)
Tool, 2017). List of anything that could possibly go wrong and that would prevent the process steps
from being successful. Some actions will benefit to avoid multiple problems. Recheck the improved
process and consult management for

Effectiveness Of Risk Identification And Analysis Of...
Abstract – Risk is present in all projects irrespective of their size or sector. If risks are not properly
analyzed and strategies are not developed to deal with them, the project is likely to lead to failures.
Therefore, special strategies and processes should be established during the initial phases of the
project and also monitored throughout the project life cycle. There are different techniques of risk
identification and analysis in construction projects. Applicability of various risk assessment
techniques has been demonstrated by many researchers. Failure Mode and Effects Analysis (FMEA)
is a logical, proactive technique that is used to identify and eliminate potential causes of failures.
The standard FMEA process evaluates failure modes for occurrence, severity, and detection. In the
project various factors causing risks in construction projects of Mumbai city of multi–storeyed
building are studied. Pareto has been applied to prioritize the risk obtained from FMEA analysis.
RPN (risk priority number) is used to focus corrective action. Risk mitigation plans covers both
preventive actions to prevent the risk from occurring as well as a suitable response in case the risk
actually occurs. keywords: SCM, FMEA, Project life cycle, RPN, Risk analysis. I.
INTRODUCTION
The supply chain management (SCM) literature offers many variations on the same theme when
defining a supply chain. The most common definition, as

The Failure Mode And Effects Analysis
The Failure Mode & Effects Analysis (FMEA) can be described as a risk and reliability tool for
management. The most prominent proactive risk assessment technique used within healthcare has
been Failure Mode and Effects Analysis (FMEA) (Shebl, Franklin, & Barber, 2012). FMEA is an
organized and qualitative tool to help physicians anticipate what might go wrong with a process or
product and how the failure effects the patient. FMEA can also help find the possible causes of
failures and the likelihood of failures being detected before it happens. There are three criteria for an
FMEA: 1) the severity of the effect on the patient 2) how frequently the problem is likely to occur
and 3) how easily the problem can be detected. The severity ... Show more content on
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Risk Management is a process of identifying hazards associated risks, controlling risks, and
monitoring the effectiveness. The use of FMEA in health care was performed in the early 1990s.
Since then, FMEA has been used in a variety of complex processes comprising of multiple steps that
could result in failure. FMEA is designed to dissect a particular process into its individual steps,
isolate the potential steps that could cause the problem, assign a specific risk level to each abnormal
step, analyze the risk potential for the process, and assign and action plan to correct the problem
(Fibuch & Ahmed, 2014). The FMEA is a method that examines potential failures in processes. It
can also be used to evaluate risk management priorities for modifying potential problems. Risk
management can help avoid or eliminate risks by identifying an alternate solution which eliminates
the risk. Additionally, risk management can prevent or mitigate risk by planning a preventive action.
This can help physicians improve quality or care for the patients while reducing costs for the health
care system.
A sentinel event is defined as any unanticipated event in a healthcare setting resulting in death or
serious psychological or physical injury to a patient. The goal is to avoid adverse events that could
potentially cause harm to the patients, employees, families, or others in the patient care setting.
FMEA can help identify and

Paper on Work Place Safety
EMP 5103
RELIABILITY, QUALITY AND SAFETY ENGINEERING
EMP 5103 TERM PROJECT ON: WORKPLACE SAFETY
SUMMARY
In this paper, workplace safety is discussed. Analysis of historical data on workplace accidents were
used to establish the need and importance of workplace safety.
Relationship between Safety and Reliability Engineering was established to show how reliability
engineering techniques and methods can be used to evaluate, identify risk prone activities and
machines, with a view of reducing to the bear minimum the faulty equipment and/or factors that
cause workplace accidents.
Safety management and safety programs like ... Show more content on Helpwriting.net ...
Alice Hamilton became the first woman physician appointed to a faculty position at Harvard
University, where she worked at the School of Public Health promoting safe and healthful work
practices in the United States. She has been recognized as the leader of the occupational medicine
movement in the United States, which came relatively late compared with that in Europe.
Early humans took necessary precautions to guard against natural hazards around them. Also, in
2000 B.C., Hammurabi, an ancient Babylonian ruler, developed a code known as Code of
Hammurabi. This code included clauses on items such as monetary damages against people who
caused injury to others and allowable fees for physicians.
It is Workplace Safety has been an age old issue. Humans have always sought to be safe and secure
within their workplace while also ensuring the protection and prolong use of machines and
equipment.
Timeline for the Development of Safety
– Pliny the Elder (23–79 AD): during grinding tasks, workers were instructed that they must wear
masks (historia naturalis)
– 1893 in the USA: Rail Safety Act
– 1938 in the USA: Food, Drugs and Cosmetic Act
– 1970: Occupational Safety and Health Act
– Nuclear regulatory commission
– Consumer product safety

– Commission
– National Transportation Safety Board
– Federal Aviation Agency (FAA)
1.2 WORKPLACE SAFETY.
Safety is the preservation of human life and the prevention of accidents and damage

An Improved Approach Of Conscious Sedation
An Improved Approach to Conscious Sedation Amy Shapen Western Governors University An
Improved Approach to Conscious Sedation This task will analyze a given patient scenario with a
poor outcome and a root cause analysis will determine the causative factors that led to the event, a
plan for improvement will de proposed, and analysis of the likelihood the improvements will be
successful will be recommended. Patient Summary One afternoon a 67 year–old man presented to
the emergency department of a small, rural hospital complaining of severe left leg and hip pain
following a fall at home. The patient had no past history of falls. He had a history of impaired
glucose intolerance, prostate cancer, hypercholesterolemia and hyperlipidemia. The patient's current
medications were atorvastatin and oxycodone for chronic back pain. The patient stated his pain was
ten out of ten on a scale of one to ten with ten being the worst. The left leg appeared shorter than the
right, edema was present in the calf, as was ecchymosis and he had limited range of motion. After
an evaluation in triage by a registered nurse and a subsequent examination by the emergency
department physician, a plan was established to sedate the patient using moderation sedation
protocol and perform a manual reduction of the hip. Root Cause Analysis The patient was sedated
with diazepam and hydromorphone, appeared to be sedated, and a successful reduction took place.
After the procedure, the

Comparing The Failure Modes And Effects Analysis And The...
The Failure Modes and Effects Analysis (FMEA) and the Root Cause Analysis (RCA) are both used
to prevent adverse events from happening. However, they are used at different time periods.
Understanding how they are used helps one to understand when to use them. The FMEA is a process
that is used before an error has occurred. It is recommended by the Institute for Healthcare
Improvement (IHI) to use the FMEA as a proactive way in which to assess for not only the risk of
failure but also to protect the patient from harm (Sorrentino, 2016). In a study it was described as "a
risk analysis technique designed to identify and analyze failure modes, causes, and effects in a
system or process before actual sentinel events or near misses occur" (Nielsen,

Advanced Design Methodologies : The Pros And Cons
Term Paper
Advanced Design Methodologies
Fall 2014
001
EVALUATION OF DFMEA FRAMEWORK: THE PROS AND CONS
VARUN KUMAR Graduate student Clemson University Clemson, SC, USA
ABSTRACT
This article presents a subjective evaluation of the Design Failure Mode and Effect Analysis
(DFMEA) framework. The advantages and disadvantages of DFMEA have been briefly discussed.
Finally, methods for further improving the effectiveness of this tool have been discussed, with a
mindset of making it more useful in an industrial setup.
INTRODUCTION Engineering design is a relatively new field of study, which continues to prosper
day by day. The variety and volume of research being done in this field explains the importance of
this discipline. Design tools, which help in improving design process are a center of attraction for
all, design practitioners and industries alike. Numerous tools have been developed over the years, to
improve design quality. The DFMEA is one such tool, which aims to improve product quality by
identifying possible modes of failure early in the design phase. The American Society for Quality
define FMEA as "a step–by–step approach for identifying all possible failures in a design, a
manufacturing or assembly process, or a product or service".
FMEA originated as a formal design process in 1960, from the Aerospace industry. Thereafter,

Wgu Rtt1 Task2 Essay
RTT1 Task 2 Never events are serious medical errors that are often preventable. When such events
transpire, it is necessary to fully assess the situation so that these errors can be prevented in the
future. Root cause analysis (RCA) is a tool employed by healthcare facilities to analyze adverse
events and the systems that lead to them.
A. Root Cause Analysis
"A central tenet of RCA is to identify underlying problems that increase the likelihood of errors
while avoiding the trap of focusing on mistakes by individuals" (AHRQ, 2012). The emphasis of
RCA is on error prevention. It is a structured process of gathering data regarding the event,
analyzing the information, and finding solutions to the problems to prevent reoccurrences. A ...
Show more content on Helpwriting.net ...
There was additional backup staff present (including a respiratory therapist) that could have been
called upon for help, yet they never were. The charge nurse or nurse supervisor could have stepped
in at this point to provide additional help. A lack of present nursing staff and support can lead to
unfavorable patient outcomes, as is the case with Mr. B. Additionally, the staff on duty could have
lacked training regarding protocols or their training could have been out of date.
A1. Errors or Hazards
Not only did insufficient staffing contribute to the causes of this particular event, but human error
also played a significant role. When Mr. B arrived at the ED, he was hyperventilating. His leg
"appeared shortened." He had edema in his calf, ecchymosis, limited ROM, and he rated his pain at
a ten out of ten. Mr. B also had a history of prostate cancer, impaired glucose tolerance, elevated
cholesterol and lipids, and chronic pain. He was admitted to the ED with a plan to relocate his hip.
Dr. T ordered diazepam 5.0 mg to be administered through IVP and then just five minutes later
ordered 2.0 mg hydromorphone to be administered because it appeared that the diazepam was not
having the intended sedating effect. Again, just five minutes later, Dr. T was still not satisfied with
the level of sedation and instructed the nurse to

Statement For MS Industrial Engineering
Program: MS Industrial Engineering Applicant Name: Venkatesh Manohar
Demand of both technical background and management capabilities are keeping me enthralled with
the field of industrial engineering. After twenty one months of industrial experience as Junior
Manager at JSW Steel Coated Products Ltd, I strongly feel that bachelor degree in mechanical
engineering is not sufficient for survival in this competitive field and hence I decided to explore
more by pursing MS Industrial Engineering at X Y Z.
My passion for engineering drove me to choose Physics, Chemistry and Mathematics at my high
school. After passing my high school examination with flying colors, I decided to pursue
Mechanical Engineering as my undergraduate major. I chose Mechanical because of its perfect
blend with many engineering fields such as Aerospace, Manufacturing, Industrial, Electronics and
what not. My undergraduate study was a judicious mix of core courses from various fields. I got
interested in industrial engineering after taking subjects like Engineering Economics and Analysis,
Operations Research, Manufacturing Planning and Control and Computer Aided Design and
Manufacturing.
My inclination drove me to do a project in quality control titled," Improving the Dimensional
Accuracy of Pump ... Show more content on Helpwriting.net ...
In the intermittent period my enthusiasm introduced me to a new concept viz 'Failure Mode and
Effect Analysis (FMEA)'. I have studied the fundamental principles of FMEA by discussing along
with my fellow classmates and professors. We also did two case studies on punching process and
sparkplug using FMEA principles. We got overwhelmed when both of our works got selected and
published in international journals (see my

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