RISK MANAGEMENT Essays

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:
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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
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Standardize patient identifiers among different departments e.g. name, birth, unique patient number
Have a protocol for comatose and mental patients e.g. tagging
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Intervention
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Even if a patient is familiar, check the details of the patient's identifier to ensure right patient receives right care
Patients
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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
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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

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 onMaintenance workshopYearsiServiced
vehicles per year, SiNo. of failure per year, fiIdentified causes of failureProposed remedy
1Private carsWorkshop (A)200714912OL, OD, TBM, PR,

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
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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

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'shospital 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

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

Essay RTT Role of Organizations
Running Head: ORGANIZATIONAL SYSTEMS1
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. Aroot 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
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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

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

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 Helpwriting.net ...
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

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
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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

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

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,

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
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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

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,

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

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

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 Helpwriting.net ...
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

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 Helpwriting.net ...
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

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,

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
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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

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

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 Helpwriting.net ...
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

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,

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

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

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%.
оЂЂ
Evaluation
The evaluation phase all interdisciplinary team members and their part in the interaction of patient care. Assessments graded for what worked well

Public Relations Personnel : Graphic Artists And Designers
Newspapers01–June–2017 to 31–Aug– 2017 3 months6 times over a period of 3 months Public relations personnel, Copywriter, Graphic artists and
designersPublic 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 PlanHow You Would Address These Issues to Facilitate the Continuous Improvement to Meet the
Designed Targets External InterferenceUnderstanding 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 BudgetAt 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
FailureThe Failure Modes and Effects Analysis (FMEA) is employed to analyse risk management for OHS, environment and quality management.
FMEA is

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

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

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 Helpwriting.net ...
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

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 Helpwriting.net ...
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. Aforward 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

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 Helpwriting.net ...
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

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

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

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.

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/SвЂЎ 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

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 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).

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

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