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Child abuse:Protest/Rally Handout
Child abuse
I have written a paper, which is about the Child Abuse, and it
includes the following points:
• Child abuse.
• Physical Abuse.
• Sexual Violence.
• Negligence.
• Emotional Exploitation.
For this reason, I need a Protest/Rally Handout about my paper,
which I wrote, and it has to be:
· 300 words minimum.
· Opening: headline.
· Action/Organization/Cause Introduction: two to three
sentences maximum. Strong, direct writing.
· Bulleted list of statistics (with sources); quotes; and action
needed. Practice parallelism by matching first words in bulleted
list; use active verbs to introduce bulleted items, when possible;
and, highlight necessary stats and quotes with bold and/or
italics.
· Closing: Call to Action and ways to reach you/org.
Note: the Protest/Rally Handout should include all of the points
which were included in my paper. Child abuse, Physical Abuse,
Sexual Violence, Negligence and Emotional Exploitation.
Example
Protest/Rally has to be the same of this example.
SUBDOMAIN 734.3 - ORGANIZATIONAL SYSTEMS & QUA
LITY LEADERSHIP
Competencies: 734.3.1: Principles of Leadership - The graduate
applies principles of leadership to promote high-quality
healthcare in a variety of settings through the application of sou
nd leadership principles.
734.3.2: Interdisciplinary Collaboration - The graduate applies t
heoretical principles necessary for effective participation in an
interdisciplinary team.
734.3.3: Quality and Patient Safety - The graduate applies qualit
y improvement processes intended to achieve optimal healthcare
outcomes, contributing to and supporting a culture of safety.
734.3.4: Healthcare Utilization and Finance - The graduate anal
yzes financial implications related to healthcare delivery,
reimbursement, access, and national initiatives
Introduction:
Healthcare organizations accredited by the Joint Commission ar
e required to conduct a root cause analysis (RCA) in response to
any
sentinel event such as the one described below. Once the cause i
s identified and a plan of action established, it is useful to cond
uct a
failure mode and effects analysis (FMEA) to reduce the likeliho
od that a process would fail. As a member of the healthcare tea
m in the
hospital described in this scenario, you have been selected as a
member of the team investigating the incident.
Scenario:
It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, a
rrives at the six-room emergency department (ED) of a sixty-be
d
rural hospital. He has been brought to the hospital by his son an
d neighbor. At this time, Mr. B is moaning and complaining of s
evere
pain to his (L) leg and hip area. He states he lost his balance an
d fell after tripping over his dog.
Mr. B was admitted to the triage room where his vital signs wer
e B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight wa
s
recorded at 175 pounds. Mr. B. states that he has no known aller
gies and no previous falls. He states, “My hip area and leg hurt
really
bad. I have never had anything like this before.” Patient rates pa
in at ten out of ten on the numerical verbal pain scale. He appea
rs to
be in moderate distress. His (L) leg appears shortened with swel
ling (edema in the calf), ecchymosis, and limited range of motio
n
(ROM). Mr. B’s leg is stabilized and then he is further evaluate
d and discharged from triage to the emergency department (ED)
patient
room. He is admitted by Nurse J. The admitting nurse finds that
Mr. B has a history of impaired glucose tolerance and prostate c
ancer.
At Mr. B’s last visit with his primary care physician, laboratory
data revealed elevated cholesterol and lipids. Mr. B’s current
medications are atorvastatin and oxycodone for chronic back pai
n. After the nurse completes Mr. B’s assessment, Nurse J inform
s the
ED physician of admission findings and the ED physician proce
eds to examine Mr. B.
Staffing on this day consists of two nurses (one RN and one LP
N), one secretary, and one emergency department physician.
Respiratory therapy is in-house and available as needed. At the t
ime of Mr. B’s arrival, the ED staff is caring for two other patie
nts.
One patient is a 43-year-old female complaining of a throbbing
headache. The patient rates current pain at four out of ten on
numerical verbal pain scale. The patient states that she has a his
tory of migraines. She received treatment, remains stable, and
discharge is pending. The second patient is an eight-year-old bo
y being evaluated for possible appendicitis. Laboratory results a
re
pending for this patient. Both of these patients were examined,
evaluated, and cared for by the ED physician and are awaiting f
urther
treatment or orders.
After evaluation of Mr. B, Dr. T, the ED physician, writes the o
rder for Nurse J to administer diazepam 5 mg IVP to Mr. B. The
medication diazepam is administered IVP at 4:05 p.m. After fiv
e minutes, the diazepam appears to have had no effect on Mr. B,
and
Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP.
The medication (hydromorphone) is administered IVP at 4:15 p.
m.
After five minutes, Dr. T is still not satisfied with the level of s
edation Mr. B has achieved and instructs Nurse J to administer a
nother 2
mg of hydromorphone IVP and an additional 5 mg of diazepam I
VP. The physician’s goal is for the patient to achieve skeletal m
uscle
relaxation from the diazepam, which will aid in the manual man
ipulation, relocation, and alignment of Mr. B’s hip. The hydrom
orphone
IVP was administered to achieve pain control and sedation. Afte
r reviewing the patient’s medical history, Dr. T notes that the pa
tient’s
weight and current regular use of oxycodone appear to be makin
g it more difficult to sedate Mr. B.
Finally at 4:25, the patient appears to be sedated and the succes
sful reduction of his (L) hip takes place. The patient appears to
have
tolerated the procedure and remains sedated. He is not currently
on any supplemental oxygen. The procedure concludes at 4:30
p.m.
and Mr. B is resting without indications of discomfort and distre
ss. At this time, the ED receives an emergency dispatch call aler
ting
the emergency department that the emergency rescue unit param
edics are en route with a 75-year-old patient in acute respiratory
distress. Nurse J places Mr. B on an automatic blood pressure m
achine programmed to monitor his B/P every five minutes and a
pulse
oximeter. At this time Nurse J leaves his room. The nurse allow
s Mr. B’s son to sit with him as he is being monitored via the bl
ood
pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat
is 92%. He remains without supplemental oxygen and his ECG a
nd
respirations are not monitored.
Nurse J and the LPN on duty have received the emergency trans
port patient. They are also in the process of discharging the othe
r two
patients. Meanwhile, the ED lobby has become congested with n
ew incoming patients. At this time, Mr. B’s O2 saturation alarm
is
heard and shows “low O2 saturation” (currently showing a sat o
f 85%). The LPN enters Mr. B’s room briefly and resets the alar
m and
repeats the B/P reading.
Nurse J is now fully engaged with the emergency care of the res
piratory distress patient, which includes assessments, evaluation
, and
the ordering respiratory treatments, CXR, labs, etc.
At 4:43, Mr. B’s son comes out of the room and informs the nur
se that the “monitor is alarming.” When Nurse J enters the room
, the
blood pressure machine shows Mr. B’s B/P reading is 58/30 and
the O2 sat is 79%. The patient is not breathing and no palpable
pulse
can be detected.
A STAT CODE is called and the son is escorted to the waiting r
oom. The code team arrives and begins resuscitative efforts. Wh
en
connected to the cardiac monitor, Mr. B is found to be in ventri
cular fibrillation. CPR begins immediately by the RN, and Mr.
B is
intubated. He is defibrillated and reversal agents, IV fluids, and
vasopressors are administered. After 30 minutes of intervention
s, the
ECG returns to a normal sinus rhythm with a pulse and a B/P of
110/70. The patient is not breathing on his own and is fully
dependent on the ventilator. The patient’s pupils are fixed and d
ilated. He has no spontaneous movements and does not respond
to
noxious stimuli. Air transport is called and, upon the family’s w
ishes, the patient is transferred to a tertiary facility for advance
d care.
Seven days later, the receiving hospital informed the rural hospi
tal that EEG’s had determined brain death in Mr. B. The family
had
requested life-support be removed, and Mr. B subsequently died
.
Additional information: The hospital where Mr. B. was originall
y seen and treated had a moderate sedation/analgesia (“consciou
s
sedation”) policy that requires that the patient remains on contin
uous B/P, ECG, and pulse oximeter throughout the procedure an
d
until the patient meets specific discharge criteria (i.e., fully awa
ke, VSS, no N/V, and able to void). All practitioners who perfor
m
moderate sedation must first successfully complete the hospital’
s moderate sedation training module. The training module inclu
des
drug selection as well as acceptable dose ranges. Additional (ba
ckup) staff was available on the day of the incident. Nurse J had
completed the moderate sedation module. Nurse J had current A
CLS certification and was an experienced critical care nurse. Nu
rse J’s
prior annual clinical evaluations by the manager demonstrated t
hat the nurse was “meeting requirements.” Nurse J did not have
a
history of negligent patient care. Sufficient equipment was avail
able and in working order in the ED on this day.
Task:
A. Complete a root cause analysis (RCA) that takes into consid
eration causative factors, errors, and/or hazards that led to the
sentinel event (this patient’s outcome).
B. Discuss a process improvement plan that would decrease the
likelihood of a reoccurrence of the outcome of the scenario.
1. Discuss a change theory that could be used to implement the
process improvement plan developed in B.
C. Use a failure mode and effects analysis (FMEA) to project t
he likelihood that the process improvement plan you suggest wo
uld not
fail.
1. Identify the members of the interdisciplinary team who will
be included in the FMEA.
2. Discuss steps for preparing for the FMEA.
3. Apply the three steps of the FMEA (severity, occurrence, an
d detection) to the process improvement plan created in part B.
4. Explain how you would test the interventions from the proce
ss improvement plan from part B to improve care in a similar
situation.
Note:You are not expected to carry out the full FMEA, but y
ou should explain each step, and how you would apply it to your
process improvement plan.
D. Discuss how the professional nurse may function as a leader
in promoting quality care and influencing quality improvement
activities.
E. When you use sources to support ideas and elements in a pap
er or project, provide acknowledgement of source information f
or
any content that is quoted, paraphrased or summarized. Acknow
ledgement of source information includes in-text citation noting
specifically where in the submission the source is used and a co
rresponding reference, which includes:
• Author
• Date
• Title
• Location of information (e.g., publisher, journal, or website
URL)
Note: The use of APA citation style is encouraged but is not req
uired for this task. Evaluators will offer feedback on the
acknowledgement of source information but not with regard to c
onformity with APA or other citation style. For tips on using A
PA style,
please refer to the APA Resources web link found under Genera
l Information/APA Guidelines in the left-hand panel in TaskStre
am.
Note: No more than a combined total of 30% of a submission ca
n be directly quoted or closely paraphrased from outside sources
,
even if cited correctly.
TITLE OF PAPER 1
Organizational Systems and Quality Leadership
Task 2
Your Name (without letters or titles)
TITLE OF PAPER 2
Organizational Systems and Quality Leadership Task 2
A. Root Cause Analysis
The task directions for this prompt are to complete a root cause
analysis that takes into
consideration causative factors, errors, and/or hazards that led
to the sentinel event (this patient’s
outcome). Review the IHI content on root cause analysis before
beginning this task so that you
are sure you understand the process. Then, simply follow the
steps in the process. While cause
and effect and Ishikawa diagrams are visual representations of
the relationships between the
causative factors, their use is not mandatory in this assignment.
It is better, generally, to describe
in essay form what factors are involved, and how they are
related.
You will also want to clearly identify any errors (causative
factors) and/or hazards
(contributing factors) in the scenario. List these, together with
an explanation of why you
identified them as errors or hazards. I strongly encourage you to
be very specific in which factors
you are identifying as errors, and which as hazards. You might
consider separating each into its
own paragraph in your response.
B. Improvement Plan
The task directions for this ask you to discuss a process
improvement plan that would
decrease the likelihood of a reoccurrence of the outcome of the
scenario. Think about this paper
as describing an ongoing cycle of activities surrounding the
sentinel event. In the RCA you
identify the causes of the problem, in this section you are
offering a plan to correct those causes,
and in the third section you will evaluate your plan to determine
whether it will do what you
intend it to do.
TITLE OF PAPER 3
In this prompt you are describing the changes in the process of
care for conscious
sedation that you recommend to address the causative factors
you identified in your RCA. What
specific changes do you recommend to prevent a recurrence?
B1. Change Theory
In this prompt you are to discuss a change theory that could be
used to implement the
process improvement plan developed in B. You will want to
review the material in IHI on
change theory (QI 105) so that you understand what it is, and
how it is used. Pay careful
attention that you are both describing the change theory, and
applying it to your plan of
correction. You will want to identify the theory you are using,
describe each of the steps or stage
of that theory, then describe how each of the stages will be
applied to your improvement plan.
Students have a tendency to describe one or the other, but to
then forget to combine the two into
a coherent approach to implementing their plan of correction.
After you’ve written this section,
be sure to go back and make sure that you have tied the
concepts together.
C. FMEA
The task directions for this prompt are to use a failure mode
and effects analysis (FMEA)
to project the likelihood that the process improvement plan you
suggest would not fail. This
prompt contains four sub-prompts (C1, C2, C3, and C4). These
prompts are part of your
response to C. Do not get confused or feel that you are
repeating yourself. You are simply being
guided through the process of answering this general prompt.
In this prompt, describe what the FMEA is, then provide
substantial support to imagine
how your plan would be successful and how you would use the
FMEA to determine that it would
be successful (or would not fail.) You do not need to actually
implement the FMEA, you only
need to describe how you implement it.
TITLE OF PAPER 4
C1. Members of the Interdisciplinary Team
The task directions for this prompt merely ask you to identify
the members of the
interdisciplinary FMEA team. A mere listing is probably
insufficient; you will want to provide
some justification for your choices.
C2. Pre-Steps
The task directions are to discuss the steps in preparing for the
FMEA. Be sure you
address your improvement plan in your discussion. This prompt
challenges students because the
steps are not spelled out. Consider that virtually all procedures
involve a series of steps that can
be divided into three phases: steps in preparing for the process,
the process, and the post-steps. A
careful reading of the steps of the FMEA, as outlined in the
FMEA tool available from the IHI
website, will reveal the three phases of the process. That is, the
steps that occur before the actual
FMEA begins, the analysis process itself, and the steps that
follow the analysis. To properly
answer the prompt, I would suggest clearly identifying the
steps, then describing them. That is,
“Step one is yadda, yadda, yadda.” This way the evaluator can
easily identify the steps you are
discussing.
C3. Three Steps
The task directions for this prompt are to apply the three steps
of the FMEA (Severity,
occurrence, and detection) to the process improvement plan you
created in prompt B. Again,
insure that you are clearly identifying each of the three topics
and that you are applying them to
the scenario. I strongly suggest that you discuss each in its own
paragraph and not intermingle
them. Intermingling them leads to a confused discussion and
may make it difficult for the
evaluator to clearly identify the three elements. Be sure to
describe how each is used in the
TITLE OF PAPER 5
FMEA process. A thorough discussion will include a description
of the three steps, a description
of how they might be applied to your improvement plan, and a
discussion of the purpose and
application of RPN values.
Remember that you do not have to carry out the FMEA. This
means that you do not need
to develop tables, assign numbers, and so forth. You merely
need to describe the processes
involved.
C4. Interventions
The task directions for this prompt are to explain how you
would test the interventions from the
process improvement plan from part B to improve care in a
similar situation. You want to be
very specific in describing how you might test your
improvement plan.
D. Key Role of Nurses
The task instructions for this prompt are to discuss how the
professional nurse may
function as a leader in promoting quality care and influencing
quality improvement activities.
This prompt may be a more generic discussion of how nurses
function as leaders in improving
quality of care. Think about some of the things that you have
learned in this course about the role
that nurses play in influencing quality in healthcare. Review the
IHI material and your Cherry
and Jacob text for additional ideas. Discuss WHY the nurse
plays a key role. You might consider
some of the provisions from the ANA Code of Ethics (or those
of other professional nursing
organizations).
The Reference Page
The Reference Page always starts on a new page, never at the
tail end of the final
paragraph. Use the hard page command to force a new page –
[Ctrl]-[Enter]. The Reference
TITLE OF PAPER 6
Page uses hanging indents: this document is set up with a
hanging indent on the Reference Page
if you choose to use it as a template. Sources are listed
alphabetically by first author’s last name
or by organization if no author can be found. The title of the
article is in sentence case, not title
case, and is italicized. The Online Writing Lab at Purdue is an
excellent source for guidance on
citations and referencing. Simply use an internet search engine
to find “OWL at Purdue APA
format”. Do not allow any blue underlined hyperlink to remain
when typing in a Web link. As
soon as it automatically appears, immediately backspace once to
remove it.
Referencing Your Citations
This is a good rule of thumb - If the thought didn't originate
within your cranium, it
originated within someone else's cranium, and therefore must be
cited (this includes anything
paraphrased or quoted). If it is cited, it must be listed on the
Reference page. If it is not cited, it
should NOT appear on the Reference page. Hint: anything you
looked up or read on the internet
did not originate within your cranium ☺ and that includes state
regulations, the ANA Code of
Ethics, IHI modules, course textbooks and online courses, etc.
Sources. If you use sources, include all in-text citations and
references in APA format. When
using sources to support ideas and elements in a paper or
project, the submission MUST include
APA formatted in-text citations with a corresponding reference
list for any direct quotes or
paraphrasing. It is not necessary to list sources that were
consulted if they have not been quoted
or paraphrased in the text of the paper or project. Note: No
more than a combined total of 30%
of a submission can be directly quoted or closely paraphrased
from sources, even if cited
correctly. For tips on using APA style, please refer to the APA
Handout web link included in the
APA Guidelines section. Remember: Personal correspondence
and interviews should NOT be
TITLE OF PAPER 7
listed on the reference page, because they are not discoverable
for anyone else; but they may be
cited within the document.
TITLE OF PAPER 8
References
Authors, R. & Alphabetic, O. (2010). Authors must be in
alphabetic order. Search Owl at Purdue
for APA Style Helps. http://owl.english.purdue.edu/. (try not to
allow blue hyperlinks).
Any hyperlinks on the reference page must work – the
evaluators WILL check these. Do
not hyperlink to a page within an area accessible only through
personal login, because the
evaluator does not have your login and password.
Hope-this-helps, I. (2013). Use this document to create your
own template: Fill in your own
information. Mentoring Advice Times: 7, 1-3.
Last, N. & First, I. (1998). Title in italics without caps. Town,
ST: Lippincott.
RTT1 Task 2 (0315)
value: 0.00
value: 1.00
value: 2.00
value: 3.00
value: 4.00
Score/Level
Articulation of Response (clarity, organization,
mechanics)
The candidate provides unsatisfactory
articulation of response.
The candidate provides weak
articulation of response.
The candidate provides limited
articulation of response.
The candidate provides adequate
articulation of response.
The candidate provides substantial
articulation of response.
A. Root Cause Analysis
The candidate does not complete an
appropriate root cause analysis (RCA) that takes into
consideration causative factors, errors, and/or hazards that led
to the sentinel event (this patient’s outcome).
The candidate completes an appropriate
root cause analysis (RCA), with no detail, that takes into
consideration causative factors, errors, and/or hazards that led
to the sentinel event (this patient’s outcome).
The candidate completes an appropriate
root cause analysis (RCA), with limited detail, that takes into
consideration causative factors, errors, and/or hazards that led
to the sentinel event (this patient’s outcome).
The candidate completes an appropriate
root cause analysis (RCA), with adequate detail, that takes into
consideration causative factors, errors, and/or hazards that led
to the sentinel event (this patient’s outcome).
The candidate completes an appropriate
root cause analysis (RCA), with substantial detail, that takes
into consideration causative factors, errors, and/or hazards that
led to the sentinel event (this patient’s outcome).
B. Improvement Plan
The candidate does not discuss a process
improvement plan that would decrease the likelihood of a
reoccurrence of the outcome of the scenario
The candidate provides a logical
discussion, with no detail, of a process improvement plan that
would decrease the likelihood of a reoccurrence of the outcome
of the scenario
The candidate provides a logical
discussion, with limited detail, of a process improvement plan
that would decrease the likelihood of a reoccurrence of the
outcome of the scenario
The candidate provides a logical
discussion, with adequate detail, of a process improvement plan
that would decrease the likelihood of a reoccurrence of the
outcome of the scenario.
The candidate provides a logical
discussion, with substantial detail, of a process improvement
plan that would decrease the likelihood of a reoccurrence of the
outcome of the scenario
B1. Change Theory
The candidate does not provide a logical
discussion of a change theory that could be used to implement
the process improvement plan developed in B.
The candidate provides a logical
discussion, with no detail, of a change theory that could be used
to implement the process improvement plan developed in B.
The candidate provides a logical
discussion, with limited detail, of a change theory that could be
used to implement the process improvement plan developed in
B.
The candidate provides a logical
discussion, with adequate detail, of a change theory that could
be used to implement the process improvement plan developed
in B.
The candidate provides a logical
discussion, with substantial detail, of a change theory that could
be used to implement the process improvement plan developed
in B.
C. FMEA
The candidate does not use a failure
mode and effects analysis to project the likelihood that the
process improvement plan suggested would not fail.
The candidate uses a failure mode and
effects analysis, with no support, to project the likelihood that
the process improvement plan suggested would not fail.
The candidate uses a failure mode and
effects analysis, with limited support, to project the likelihood
that the process improvement plan suggested would not fail.
The candidate uses a failure mode and
effects analysis, with adequate support, to project the likelihood
that the process improvement plan suggested would not fail.
The candidate uses a failure mode and
effects analysis, with substantial support, to project the
likelihood that the process improvement plan suggested would
not fail.
C1. Members of the Interdisciplinary Team
The candidate does not accurately
identify the members of the interdisciplinary team who will be
included in the FMEA.
N/A
N/A
N/A
The candidate accurately identifies the
members of the interdisciplinary team who will be included in
the FMEA.
C2. Pre-Steps
The candidate does not provide a logical
discussion of the steps for preparing for the FMEA.
The candidate provides a logical
discussion, with no detail, of the steps for preparing for the
FMEA.
The candidate provides a logical
discussion, with limited detail, of the steps for preparing for the
FMEA.
The candidate provides a logical
discussion, with adequate detail, of the steps for preparing for
the FMEA.
The candidate provides a logical
discussion, with substantial detail, of the steps for preparing for
the FMEA.
C3. Three Steps
The candidate does not appropriately
apply the 3 steps of the FMEA (severity, occurrence, and
detection) to the process improvement plan created in part B.
The candidate appropriately applies,
with no detail, the 3 steps of the FMEA (severity, occurrence,
and detection) to the process improvement plan created in part
B.
The candidate appropriately applies,
with limited detail, the 3 steps of the FMEA (severity,
occurrence, and detection) to the process improvement plan
created in part B.
The candidate appropriately applies,
with adequate detail, the 3 steps of the FMEA (severity,
occurrence, and detection) to the process improvement plan
created in part B.
The candidate appropriately applies,
with substantial detail, the 3 steps of the FMEA (severity,
occurrence, and detection) to the process improvement plan
created in part B.
C4. Interventions
The candidate does not provide a logical
explanation of how the candidate would test the interventions
from the process improvement plan from part B to improve care
in a similar situation.
The candidate provides a logical
explanation, with no support, of how the candidate would test
the interventions from the process improvement plan from part
B to improve care in a similar situation.
The candidate provides a logical
explanation, with limited support, of how the candidate would
test the interventions from the process improvement plan from
part B to improve care in a similar situation.
The candidate provides a logical
explanation, with adequate support, how the candidate would
test the interventions from the process improvement plan from
part B to improve care in a similar situation.
The candidate provides a logical
explanation, with substantial support, of how the candidate
would test the interventions from the process improvement plan
from part B to improve care in a similar situation.
D. Key Role of Nurses
The candidate does not provide a logical
discussion of how the professional nurse may function as a
leader in promoting quality care and influencing quality
improvement activities.
The candidate provides a logical
discussion, with no detail, of how the professional nurse may
function as a leader in promoting quality care and influencing
quality improvement activities.
The candidate provides a logical
discussion, with limited detail, of how the professional nurse
may function as a leader in promoting quality care and
influencing quality improvement activities.
The candidate provides a logical
discussion, with adequate detail, of how the professional nurse
may function as a leader in promoting quality care and
influencing quality improvement activities.
The candidate provides a logical
discussion, with substantial detail, of how the professional
nurse may function as a leader in promoting quality care and
influencing quality improvement activities.
E. Sources
There is evidence of quoted,
paraphrased or summarized content without acknowledgement
of source information. This level is also appropriate if task
instructions require the candidate to quote, paraphrase or
summarize content from a source to complete the assessment,
and this has not yet been done.
The candidate provides required
acknowledgement of source information for quoted, paraphrased
and summarized content. However, in-text citations and/or
source information is incomplete or inaccurate with respect to
author, date, title and the location of the information (e.g.,
publisher, journal or website URL).
N/A
N/A
The candidate provides source
information for all quoted, paraphrased and summarized
content. Source information appears to include accurate and
complete acknowledgement of source information regarding the
author, date, title and location of the information (e.g.,
publisher, journal or website URL) as well as appropriate in-
text citation. This level is also appropriate if there is no
evidence of quoted, paraphrased or summarized content, and it
is not required by the instructions.
Child abuse protestrally handoutchild abusei have written a p

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Child abuse protestrally handoutchild abusei have written a p

  • 1. Child abuse:Protest/Rally Handout Child abuse I have written a paper, which is about the Child Abuse, and it includes the following points: • Child abuse. • Physical Abuse. • Sexual Violence. • Negligence. • Emotional Exploitation. For this reason, I need a Protest/Rally Handout about my paper, which I wrote, and it has to be: · 300 words minimum. · Opening: headline. · Action/Organization/Cause Introduction: two to three sentences maximum. Strong, direct writing. · Bulleted list of statistics (with sources); quotes; and action needed. Practice parallelism by matching first words in bulleted list; use active verbs to introduce bulleted items, when possible; and, highlight necessary stats and quotes with bold and/or italics. · Closing: Call to Action and ways to reach you/org. Note: the Protest/Rally Handout should include all of the points which were included in my paper. Child abuse, Physical Abuse, Sexual Violence, Negligence and Emotional Exploitation. Example
  • 2. Protest/Rally has to be the same of this example. SUBDOMAIN 734.3 - ORGANIZATIONAL SYSTEMS & QUA LITY LEADERSHIP Competencies: 734.3.1: Principles of Leadership - The graduate applies principles of leadership to promote high-quality healthcare in a variety of settings through the application of sou nd leadership principles. 734.3.2: Interdisciplinary Collaboration - The graduate applies t heoretical principles necessary for effective participation in an interdisciplinary team. 734.3.3: Quality and Patient Safety - The graduate applies qualit y improvement processes intended to achieve optimal healthcare outcomes, contributing to and supporting a culture of safety. 734.3.4: Healthcare Utilization and Finance - The graduate anal yzes financial implications related to healthcare delivery, reimbursement, access, and national initiatives Introduction: Healthcare organizations accredited by the Joint Commission ar e required to conduct a root cause analysis (RCA) in response to any sentinel event such as the one described below. Once the cause i s identified and a plan of action established, it is useful to cond uct a failure mode and effects analysis (FMEA) to reduce the likeliho od that a process would fail. As a member of the healthcare tea m in the hospital described in this scenario, you have been selected as a
  • 3. member of the team investigating the incident. Scenario: It is 3:30 p.m. on a Thursday and Mr. B, a 67-year-old patient, a rrives at the six-room emergency department (ED) of a sixty-be d rural hospital. He has been brought to the hospital by his son an d neighbor. At this time, Mr. B is moaning and complaining of s evere pain to his (L) leg and hip area. He states he lost his balance an d fell after tripping over his dog. Mr. B was admitted to the triage room where his vital signs wer e B/P 120/80, HR-88 (regular), T-98.6, R-32, and his weight wa s recorded at 175 pounds. Mr. B. states that he has no known aller gies and no previous falls. He states, “My hip area and leg hurt really bad. I have never had anything like this before.” Patient rates pa in at ten out of ten on the numerical verbal pain scale. He appea rs to be in moderate distress. His (L) leg appears shortened with swel ling (edema in the calf), ecchymosis, and limited range of motio n (ROM). Mr. B’s leg is stabilized and then he is further evaluate d and discharged from triage to the emergency department (ED) patient room. He is admitted by Nurse J. The admitting nurse finds that Mr. B has a history of impaired glucose tolerance and prostate c ancer. At Mr. B’s last visit with his primary care physician, laboratory data revealed elevated cholesterol and lipids. Mr. B’s current medications are atorvastatin and oxycodone for chronic back pai n. After the nurse completes Mr. B’s assessment, Nurse J inform s the
  • 4. ED physician of admission findings and the ED physician proce eds to examine Mr. B. Staffing on this day consists of two nurses (one RN and one LP N), one secretary, and one emergency department physician. Respiratory therapy is in-house and available as needed. At the t ime of Mr. B’s arrival, the ED staff is caring for two other patie nts. One patient is a 43-year-old female complaining of a throbbing headache. The patient rates current pain at four out of ten on numerical verbal pain scale. The patient states that she has a his tory of migraines. She received treatment, remains stable, and discharge is pending. The second patient is an eight-year-old bo y being evaluated for possible appendicitis. Laboratory results a re pending for this patient. Both of these patients were examined, evaluated, and cared for by the ED physician and are awaiting f urther treatment or orders. After evaluation of Mr. B, Dr. T, the ED physician, writes the o rder for Nurse J to administer diazepam 5 mg IVP to Mr. B. The medication diazepam is administered IVP at 4:05 p.m. After fiv e minutes, the diazepam appears to have had no effect on Mr. B, and Dr. T instructs Nurse J to administer hydromorphone 2 mg IVP. The medication (hydromorphone) is administered IVP at 4:15 p. m. After five minutes, Dr. T is still not satisfied with the level of s edation Mr. B has achieved and instructs Nurse J to administer a nother 2 mg of hydromorphone IVP and an additional 5 mg of diazepam I VP. The physician’s goal is for the patient to achieve skeletal m
  • 5. uscle relaxation from the diazepam, which will aid in the manual man ipulation, relocation, and alignment of Mr. B’s hip. The hydrom orphone IVP was administered to achieve pain control and sedation. Afte r reviewing the patient’s medical history, Dr. T notes that the pa tient’s weight and current regular use of oxycodone appear to be makin g it more difficult to sedate Mr. B. Finally at 4:25, the patient appears to be sedated and the succes sful reduction of his (L) hip takes place. The patient appears to have tolerated the procedure and remains sedated. He is not currently on any supplemental oxygen. The procedure concludes at 4:30 p.m. and Mr. B is resting without indications of discomfort and distre ss. At this time, the ED receives an emergency dispatch call aler ting the emergency department that the emergency rescue unit param edics are en route with a 75-year-old patient in acute respiratory distress. Nurse J places Mr. B on an automatic blood pressure m achine programmed to monitor his B/P every five minutes and a pulse oximeter. At this time Nurse J leaves his room. The nurse allow s Mr. B’s son to sit with him as he is being monitored via the bl ood pressure monitor. At 4:35, Mr. B’s B/P is 110/62 and his O2 sat is 92%. He remains without supplemental oxygen and his ECG a nd respirations are not monitored. Nurse J and the LPN on duty have received the emergency trans port patient. They are also in the process of discharging the othe r two patients. Meanwhile, the ED lobby has become congested with n
  • 6. ew incoming patients. At this time, Mr. B’s O2 saturation alarm is heard and shows “low O2 saturation” (currently showing a sat o f 85%). The LPN enters Mr. B’s room briefly and resets the alar m and repeats the B/P reading. Nurse J is now fully engaged with the emergency care of the res piratory distress patient, which includes assessments, evaluation , and the ordering respiratory treatments, CXR, labs, etc. At 4:43, Mr. B’s son comes out of the room and informs the nur se that the “monitor is alarming.” When Nurse J enters the room , the blood pressure machine shows Mr. B’s B/P reading is 58/30 and the O2 sat is 79%. The patient is not breathing and no palpable pulse can be detected. A STAT CODE is called and the son is escorted to the waiting r oom. The code team arrives and begins resuscitative efforts. Wh en connected to the cardiac monitor, Mr. B is found to be in ventri cular fibrillation. CPR begins immediately by the RN, and Mr. B is intubated. He is defibrillated and reversal agents, IV fluids, and vasopressors are administered. After 30 minutes of intervention s, the ECG returns to a normal sinus rhythm with a pulse and a B/P of 110/70. The patient is not breathing on his own and is fully dependent on the ventilator. The patient’s pupils are fixed and d ilated. He has no spontaneous movements and does not respond to noxious stimuli. Air transport is called and, upon the family’s w ishes, the patient is transferred to a tertiary facility for advance
  • 7. d care. Seven days later, the receiving hospital informed the rural hospi tal that EEG’s had determined brain death in Mr. B. The family had requested life-support be removed, and Mr. B subsequently died . Additional information: The hospital where Mr. B. was originall y seen and treated had a moderate sedation/analgesia (“consciou s sedation”) policy that requires that the patient remains on contin uous B/P, ECG, and pulse oximeter throughout the procedure an d until the patient meets specific discharge criteria (i.e., fully awa ke, VSS, no N/V, and able to void). All practitioners who perfor m moderate sedation must first successfully complete the hospital’ s moderate sedation training module. The training module inclu des drug selection as well as acceptable dose ranges. Additional (ba ckup) staff was available on the day of the incident. Nurse J had completed the moderate sedation module. Nurse J had current A CLS certification and was an experienced critical care nurse. Nu rse J’s prior annual clinical evaluations by the manager demonstrated t hat the nurse was “meeting requirements.” Nurse J did not have a history of negligent patient care. Sufficient equipment was avail able and in working order in the ED on this day. Task:
  • 8. A. Complete a root cause analysis (RCA) that takes into consid eration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). B. Discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario. 1. Discuss a change theory that could be used to implement the process improvement plan developed in B. C. Use a failure mode and effects analysis (FMEA) to project t he likelihood that the process improvement plan you suggest wo uld not fail. 1. Identify the members of the interdisciplinary team who will be included in the FMEA. 2. Discuss steps for preparing for the FMEA. 3. Apply the three steps of the FMEA (severity, occurrence, an d detection) to the process improvement plan created in part B. 4. Explain how you would test the interventions from the proce ss improvement plan from part B to improve care in a similar situation. Note:You are not expected to carry out the full FMEA, but y ou should explain each step, and how you would apply it to your process improvement plan. D. Discuss how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities.
  • 9. E. When you use sources to support ideas and elements in a pap er or project, provide acknowledgement of source information f or any content that is quoted, paraphrased or summarized. Acknow ledgement of source information includes in-text citation noting specifically where in the submission the source is used and a co rresponding reference, which includes: • Author • Date • Title • Location of information (e.g., publisher, journal, or website URL) Note: The use of APA citation style is encouraged but is not req uired for this task. Evaluators will offer feedback on the acknowledgement of source information but not with regard to c onformity with APA or other citation style. For tips on using A PA style, please refer to the APA Resources web link found under Genera l Information/APA Guidelines in the left-hand panel in TaskStre am. Note: No more than a combined total of 30% of a submission ca n be directly quoted or closely paraphrased from outside sources , even if cited correctly. TITLE OF PAPER 1
  • 10. Organizational Systems and Quality Leadership Task 2 Your Name (without letters or titles) TITLE OF PAPER 2 Organizational Systems and Quality Leadership Task 2 A. Root Cause Analysis The task directions for this prompt are to complete a root cause analysis that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). Review the IHI content on root cause analysis before beginning this task so that you are sure you understand the process. Then, simply follow the
  • 11. steps in the process. While cause and effect and Ishikawa diagrams are visual representations of the relationships between the causative factors, their use is not mandatory in this assignment. It is better, generally, to describe in essay form what factors are involved, and how they are related. You will also want to clearly identify any errors (causative factors) and/or hazards (contributing factors) in the scenario. List these, together with an explanation of why you identified them as errors or hazards. I strongly encourage you to be very specific in which factors you are identifying as errors, and which as hazards. You might consider separating each into its own paragraph in your response. B. Improvement Plan The task directions for this ask you to discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario. Think about this paper as describing an ongoing cycle of activities surrounding the sentinel event. In the RCA you
  • 12. identify the causes of the problem, in this section you are offering a plan to correct those causes, and in the third section you will evaluate your plan to determine whether it will do what you intend it to do. TITLE OF PAPER 3 In this prompt you are describing the changes in the process of care for conscious sedation that you recommend to address the causative factors you identified in your RCA. What specific changes do you recommend to prevent a recurrence? B1. Change Theory In this prompt you are to discuss a change theory that could be used to implement the process improvement plan developed in B. You will want to review the material in IHI on change theory (QI 105) so that you understand what it is, and how it is used. Pay careful attention that you are both describing the change theory, and applying it to your plan of correction. You will want to identify the theory you are using, describe each of the steps or stage
  • 13. of that theory, then describe how each of the stages will be applied to your improvement plan. Students have a tendency to describe one or the other, but to then forget to combine the two into a coherent approach to implementing their plan of correction. After you’ve written this section, be sure to go back and make sure that you have tied the concepts together. C. FMEA The task directions for this prompt are to use a failure mode and effects analysis (FMEA) to project the likelihood that the process improvement plan you suggest would not fail. This prompt contains four sub-prompts (C1, C2, C3, and C4). These prompts are part of your response to C. Do not get confused or feel that you are repeating yourself. You are simply being guided through the process of answering this general prompt. In this prompt, describe what the FMEA is, then provide substantial support to imagine how your plan would be successful and how you would use the FMEA to determine that it would be successful (or would not fail.) You do not need to actually
  • 14. implement the FMEA, you only need to describe how you implement it. TITLE OF PAPER 4 C1. Members of the Interdisciplinary Team The task directions for this prompt merely ask you to identify the members of the interdisciplinary FMEA team. A mere listing is probably insufficient; you will want to provide some justification for your choices. C2. Pre-Steps The task directions are to discuss the steps in preparing for the FMEA. Be sure you address your improvement plan in your discussion. This prompt challenges students because the steps are not spelled out. Consider that virtually all procedures involve a series of steps that can be divided into three phases: steps in preparing for the process, the process, and the post-steps. A careful reading of the steps of the FMEA, as outlined in the FMEA tool available from the IHI
  • 15. website, will reveal the three phases of the process. That is, the steps that occur before the actual FMEA begins, the analysis process itself, and the steps that follow the analysis. To properly answer the prompt, I would suggest clearly identifying the steps, then describing them. That is, “Step one is yadda, yadda, yadda.” This way the evaluator can easily identify the steps you are discussing. C3. Three Steps The task directions for this prompt are to apply the three steps of the FMEA (Severity, occurrence, and detection) to the process improvement plan you created in prompt B. Again, insure that you are clearly identifying each of the three topics and that you are applying them to the scenario. I strongly suggest that you discuss each in its own paragraph and not intermingle them. Intermingling them leads to a confused discussion and may make it difficult for the evaluator to clearly identify the three elements. Be sure to describe how each is used in the
  • 16. TITLE OF PAPER 5 FMEA process. A thorough discussion will include a description of the three steps, a description of how they might be applied to your improvement plan, and a discussion of the purpose and application of RPN values. Remember that you do not have to carry out the FMEA. This means that you do not need to develop tables, assign numbers, and so forth. You merely need to describe the processes involved. C4. Interventions The task directions for this prompt are to explain how you would test the interventions from the process improvement plan from part B to improve care in a similar situation. You want to be very specific in describing how you might test your improvement plan. D. Key Role of Nurses The task instructions for this prompt are to discuss how the professional nurse may function as a leader in promoting quality care and influencing
  • 17. quality improvement activities. This prompt may be a more generic discussion of how nurses function as leaders in improving quality of care. Think about some of the things that you have learned in this course about the role that nurses play in influencing quality in healthcare. Review the IHI material and your Cherry and Jacob text for additional ideas. Discuss WHY the nurse plays a key role. You might consider some of the provisions from the ANA Code of Ethics (or those of other professional nursing organizations). The Reference Page The Reference Page always starts on a new page, never at the tail end of the final paragraph. Use the hard page command to force a new page – [Ctrl]-[Enter]. The Reference TITLE OF PAPER 6 Page uses hanging indents: this document is set up with a hanging indent on the Reference Page if you choose to use it as a template. Sources are listed alphabetically by first author’s last name
  • 18. or by organization if no author can be found. The title of the article is in sentence case, not title case, and is italicized. The Online Writing Lab at Purdue is an excellent source for guidance on citations and referencing. Simply use an internet search engine to find “OWL at Purdue APA format”. Do not allow any blue underlined hyperlink to remain when typing in a Web link. As soon as it automatically appears, immediately backspace once to remove it. Referencing Your Citations This is a good rule of thumb - If the thought didn't originate within your cranium, it originated within someone else's cranium, and therefore must be cited (this includes anything paraphrased or quoted). If it is cited, it must be listed on the Reference page. If it is not cited, it should NOT appear on the Reference page. Hint: anything you looked up or read on the internet did not originate within your cranium ☺ and that includes state regulations, the ANA Code of Ethics, IHI modules, course textbooks and online courses, etc. Sources. If you use sources, include all in-text citations and
  • 19. references in APA format. When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project. Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly. For tips on using APA style, please refer to the APA Handout web link included in the APA Guidelines section. Remember: Personal correspondence and interviews should NOT be TITLE OF PAPER 7 listed on the reference page, because they are not discoverable for anyone else; but they may be cited within the document. TITLE OF PAPER 8
  • 20. References Authors, R. & Alphabetic, O. (2010). Authors must be in alphabetic order. Search Owl at Purdue for APA Style Helps. http://owl.english.purdue.edu/. (try not to allow blue hyperlinks). Any hyperlinks on the reference page must work – the evaluators WILL check these. Do not hyperlink to a page within an area accessible only through personal login, because the evaluator does not have your login and password. Hope-this-helps, I. (2013). Use this document to create your own template: Fill in your own information. Mentoring Advice Times: 7, 1-3. Last, N. & First, I. (1998). Title in italics without caps. Town, ST: Lippincott. RTT1 Task 2 (0315) value: 0.00
  • 21. value: 1.00 value: 2.00 value: 3.00 value: 4.00 Score/Level Articulation of Response (clarity, organization, mechanics) The candidate provides unsatisfactory articulation of response. The candidate provides weak articulation of response. The candidate provides limited
  • 22. articulation of response. The candidate provides adequate articulation of response. The candidate provides substantial articulation of response. A. Root Cause Analysis The candidate does not complete an appropriate root cause analysis (RCA) that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). The candidate completes an appropriate root cause analysis (RCA), with no detail, that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome).
  • 23. The candidate completes an appropriate root cause analysis (RCA), with limited detail, that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). The candidate completes an appropriate root cause analysis (RCA), with adequate detail, that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). The candidate completes an appropriate root cause analysis (RCA), with substantial detail, that takes into consideration causative factors, errors, and/or hazards that led to the sentinel event (this patient’s outcome). B. Improvement Plan The candidate does not discuss a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario
  • 24. The candidate provides a logical discussion, with no detail, of a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario The candidate provides a logical discussion, with limited detail, of a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario The candidate provides a logical discussion, with adequate detail, of a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario. The candidate provides a logical discussion, with substantial detail, of a process improvement plan that would decrease the likelihood of a reoccurrence of the outcome of the scenario B1. Change Theory The candidate does not provide a logical discussion of a change theory that could be used to implement the process improvement plan developed in B.
  • 25. The candidate provides a logical discussion, with no detail, of a change theory that could be used to implement the process improvement plan developed in B. The candidate provides a logical discussion, with limited detail, of a change theory that could be used to implement the process improvement plan developed in B. The candidate provides a logical discussion, with adequate detail, of a change theory that could be used to implement the process improvement plan developed in B. The candidate provides a logical discussion, with substantial detail, of a change theory that could be used to implement the process improvement plan developed in B. C. FMEA
  • 26. The candidate does not use a failure mode and effects analysis to project the likelihood that the process improvement plan suggested would not fail. The candidate uses a failure mode and effects analysis, with no support, to project the likelihood that the process improvement plan suggested would not fail. The candidate uses a failure mode and effects analysis, with limited support, to project the likelihood that the process improvement plan suggested would not fail. The candidate uses a failure mode and effects analysis, with adequate support, to project the likelihood that the process improvement plan suggested would not fail. The candidate uses a failure mode and effects analysis, with substantial support, to project the likelihood that the process improvement plan suggested would not fail. C1. Members of the Interdisciplinary Team
  • 27. The candidate does not accurately identify the members of the interdisciplinary team who will be included in the FMEA. N/A N/A N/A The candidate accurately identifies the members of the interdisciplinary team who will be included in the FMEA. C2. Pre-Steps
  • 28. The candidate does not provide a logical discussion of the steps for preparing for the FMEA. The candidate provides a logical discussion, with no detail, of the steps for preparing for the FMEA. The candidate provides a logical discussion, with limited detail, of the steps for preparing for the FMEA. The candidate provides a logical discussion, with adequate detail, of the steps for preparing for the FMEA. The candidate provides a logical discussion, with substantial detail, of the steps for preparing for the FMEA. C3. Three Steps
  • 29. The candidate does not appropriately apply the 3 steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B. The candidate appropriately applies, with no detail, the 3 steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B. The candidate appropriately applies, with limited detail, the 3 steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B. The candidate appropriately applies, with adequate detail, the 3 steps of the FMEA (severity, occurrence, and detection) to the process improvement plan created in part B. The candidate appropriately applies, with substantial detail, the 3 steps of the FMEA (severity, occurrence, and detection) to the process improvement plan
  • 30. created in part B. C4. Interventions The candidate does not provide a logical explanation of how the candidate would test the interventions from the process improvement plan from part B to improve care in a similar situation. The candidate provides a logical explanation, with no support, of how the candidate would test the interventions from the process improvement plan from part B to improve care in a similar situation. The candidate provides a logical explanation, with limited support, of how the candidate would test the interventions from the process improvement plan from part B to improve care in a similar situation. The candidate provides a logical explanation, with adequate support, how the candidate would
  • 31. test the interventions from the process improvement plan from part B to improve care in a similar situation. The candidate provides a logical explanation, with substantial support, of how the candidate would test the interventions from the process improvement plan from part B to improve care in a similar situation. D. Key Role of Nurses The candidate does not provide a logical discussion of how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities. The candidate provides a logical discussion, with no detail, of how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities. The candidate provides a logical
  • 32. discussion, with limited detail, of how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities. The candidate provides a logical discussion, with adequate detail, of how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities. The candidate provides a logical discussion, with substantial detail, of how the professional nurse may function as a leader in promoting quality care and influencing quality improvement activities. E. Sources There is evidence of quoted, paraphrased or summarized content without acknowledgement of source information. This level is also appropriate if task instructions require the candidate to quote, paraphrase or summarize content from a source to complete the assessment, and this has not yet been done.
  • 33. The candidate provides required acknowledgement of source information for quoted, paraphrased and summarized content. However, in-text citations and/or source information is incomplete or inaccurate with respect to author, date, title and the location of the information (e.g., publisher, journal or website URL). N/A N/A The candidate provides source information for all quoted, paraphrased and summarized content. Source information appears to include accurate and complete acknowledgement of source information regarding the author, date, title and location of the information (e.g., publisher, journal or website URL) as well as appropriate in- text citation. This level is also appropriate if there is no evidence of quoted, paraphrased or summarized content, and it is not required by the instructions.