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Description: A case study is provided. The case with an adverse outcome has been
Description: A case study is provided. The case with an adverse outcome has been the subject of an incident review. You are a quality manager and have been asked to present a summary of the most important contributory factors relating to the adverse outcome at the departmental Morbidity and Mortality meeting. You will develop at least 3 contributory factors (The contributory factor is an issue where some change on the part of the organisation (a systems change) may have prevented the adverse event) that may have contributed to the adverse outcome.
You must explain the rationale behind your choice of contributory factors to the Morbidity and Mortality Committee and provide references to support your rationale. You must put forward at least 3 contributory factors. You must also suggest at least one potential action and describe interventions (low or high level) for each contributory factor that could be taken to prevent the adverse event from happening again.
The report on the case study should be set out as follows:
summation of the case in point form. (300 words).
Describe the 3 potential contributing factors you feel have been involved that may have resulted in the adverse outcome. (500 words).
Provide a summary of the rationale behind your choice of contributory factors (1000 words).
The rationale should cover the following for each contributory factor:
Which major category of issues the contributory factor relates to (it may be more than one of the seven) (e.g. communication, policies/procedures/guidelines, equipment, skills/knowledge/competence, patient factors, work environment/scheduling, safety mechanisms/barriers) and how it relates to this category.
How the contributory factor may have contributed to the adverse outcome.
Describe one potential action (for each contributory factor) and describe interventions (low or high level) that could be taken in relation to this contributory factor to prevent this adverse event from happening again.
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