Identify an error or near miss (close call) that you have encountered in the clinical practice setting. Consider the impact of the error on patient outcomes. For example, was the error disclosed to the patient and family, how did the administration respond to the error initially and were strategies implemented to prevent the error or near miss from occurring again? Please do not identify the healthcare agency where the error occurred, or the individuals involved (HIPAA). Elaborate on how the error made you feel. What thoughts and fears did it provoke in you?
As you reflect on this event, use the concepts related to a “Just Culture” (PowerPoint presentation from David Marx) and the proactive approach of “ Failure Mode Effects Analysis” (resource provided by Institute on Healthcare Improvement) and share how as a nurse leader /manager that you would address this safety concern in the healthcare organization. Discuss in detail the idea of a “second victim” and how as a manager you could provide support to your staff and promote a “just culture”. Use scholarly in-text citations to support your decisions.
Develop a narrated/voice-over/recorded PowerPoint presentation discussing the error/near miss and incorporate the ideas from David Marx’s ppt and the Failure Mode Effects Analysis on resolving the issue, second victim, and a manager’s role in handling this safety concern. Upload your narrated PowerPoint to the link provided AND in the discussion forum area on the next page as your initial post and then reply to a minimum of four of your peers . (Follow the grading rubric and do not forget to include a reference slide at the end of your PowerPoint.)
I will record my voice to PowerPoint after you finish it.
See grading rubric
## PowerPoint Presentation: Addressing Clinical Errors and Near Misses
### Slide 1: Title Slide
– **Title:** Addressing Clinical Errors and Near Misses
– **Subtitle:** Utilizing Just Culture and Failure Mode Effects Analysis
– **Your Name**
– **Course Title**
– **Date**
### Slide 2: Introduction
– **Introduction to the Topic**
– Briefly introduce the importance of addressing clinical errors and near misses.
– State the purpose of the presentation.
### Slide 3: Error/Near Miss Description
– **Description of the Incident**
– Provide a detailed but de-identified account of the error or near miss.
– Explain the circumstances under which it occurred.
### Slide 4: Impact on Patient Outcomes
– **Patient Outcomes**
– Discuss the immediate and potential long-term impacts on the patient.
– Mention if the error was disclosed to the patient and family.
### Slide 5: Initial Administrative Response
– **Administration’s Initial Response**
– Explain how the administration responded to the error.
– Detail any immediate actions taken.
### Slide 6: Strategies to Prevent Recurrence
– **Preventive Strategies Implemented**
– Describe the strategies implemented to prevent the error from recurring.
– Discuss any changes in policies or procedures.
### Slide 7: Personal Reflection
– **Personal Feelings and Reactions**
– Share your personal feelings about the error.
– Discuss any thoughts and fears it provoked in you.
### Slide 8: Concepts of a Just Culture
– **Just Culture Overview**
– Introduce the concept of a Just Culture as presented by David Marx.
– Discuss its principles and importance in healthcare.
### Slide 9: Applying Just Culture
– **Application in Addressing the Error**
– Explain how you would apply Just Culture principles to address the error.
– Discuss how this approach supports both accountability and learning.
### Slide 10: Failure Mode Effects Analysis (FMEA)
– **Introduction to FMEA**
– Explain what Failure Mode Effects Analysis is.
– Describe its purpose in healthcare settings.
### Slide 11: Using FMEA to Address the Error
– **Application of FMEA**
– Detail the steps you would take to apply FMEA to the error.
– Discuss how FMEA helps identify and mitigate potential failures.
### Slide 12: Supporting the Second Victim
– **Second Victim Concept**
– Define the term “second victim.”
– Discuss the emotional impact on healthcare providers involved in errors.
### Slide 13: Providing Support as a Manager
– **Managerial Support Strategies**
– Outline strategies to support staff as a nurse leader/manager.
– Emphasize promoting a Just Culture and supporting second victims.
### Slide 14: Conclusion
– **Summary of Key Points**
– Recap the main points discussed in the presentation.
– Reinforce the importance of addressing errors through Just Culture and FMEA.
### Slide 15: References
– **Reference List**
– Provide APA-formatted references for all sources cited in the presentation.
—
### Narration Script (for each slide):
#### Slide 1: Title Slide
“Welcome to my presentation on addressing clinical errors and near misses. Today, I will discuss the concepts of Just Culture and Failure Mode Effects Analysis, and how they can be applied to manage and prevent clinical errors.”
#### Slide 2: Introduction
“Clinical errors and near misses are critical issues in healthcare. This presentation aims to explore how we can effectively address these incidents to improve patient safety and outcomes.”
#### Slide 3: Error/Near Miss Description
“I encountered a near miss where a medication dosage error almost occurred due to a miscommunication during a shift change. The patient was supposed to receive 5 mg of a medication, but the order was misunderstood as 50 mg.”
#### Slide 4: Impact on Patient Outcomes
“Had the error occurred, the patient could have experienced severe adverse effects. Fortunately, the mistake was caught in time. The incident highlighted the need for clearer communication and double-checking medication orders.”
#### Slide 5: Initial Administrative Response
“The administration responded promptly by conducting an immediate review of the incident. They held a debriefing session with the involved staff and emphasized the importance of vigilance in medication administration.”
#### Slide 6: Strategies to Prevent Recurrence
“To prevent similar incidents, the administration introduced mandatory read-back protocols for all medication orders and reinforced training on medication safety. These measures aimed to enhance communication and accuracy.”
#### Slide 7: Personal Reflection
“This near miss was a wake-up call for me. It made me anxious about the potential harm to the patient and underscored the weight of responsibility we carry as healthcare providers.”
#### Slide 8: Concepts of a Just Culture
“A Just Culture encourages an environment where staff can report errors without fear of punishment. It balances accountability with learning, ensuring that mistakes lead to system improvements rather than individual blame.”
#### Slide 9: Applying Just Culture
“To address the error, I would apply Just Culture principles by conducting a thorough and fair investigation. This approach ensures that the root causes are identified and that staff feel supported rather than blamed.”
#### Slide 10: Failure Mode Effects Analysis (FMEA)
“FMEA is a proactive tool used to identify and mitigate potential failures in processes. It involves analyzing each step in a process to detect where and how it might fail, and the impact of such failures.”
#### Slide 11: Using FMEA to Address the Error
“I would use FMEA to review the medication administration process, identifying potential failure points such as miscommunication and unclear orders. This analysis would guide us in implementing safeguards to prevent future errors.”
#### Slide 12: Supporting the Second Victim
“The term ‘second victim’ refers to healthcare providers who are emotionally affected by errors. Recognizing their distress is crucial, as they need support to recover and continue providing safe care.”
#### Slide 13: Providing Support as a Manager
“As a manager, I would offer emotional support and counseling to affected staff. Promoting a Just Culture involves creating a supportive environment where staff feel safe to discuss and learn from errors.”
#### Slide 14: Conclusion
“In conclusion, addressing clinical errors requires a balanced approach that includes Just Culture principles and proactive tools like FMEA. These strategies help create a safer healthcare environment for both patients and providers.”
#### Slide 15: References
“Here are the references for the sources I used in this presentation. Thank you for your attention.”
—
**References:**
– Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives.
– Institute for Healthcare Improvement. (2021). Failure Modes and Effects Analysis Tool.
– Additional scholarly sources (to be included based on the content and citations used in the presentation).
—
### Grading Rubric:
- **Content (40 points)**
– Clearly describe the error/near miss.
– Thoroughly discuss the impact on patient outcomes and initial administrative response.
– Apply Just Culture and FMEA concepts effectively.
– Provide strategies for supporting second victims.
- **Organization (20 points)**
– Logical flow and clarity.
– Appropriate use of headings and subheadings.
– Clear and concise narration.
- **Use of Resources (20 points)**
– Cite at least 4 scholarly sources.
– Use APA format for references.
- **Presentation Skills (20 points)**
– Engaging and clear narration.
– Professional tone and language.
– Proper use of visuals and text in slides.
Feel free to record your narration using this script, and ensure each slide is visually appealing and supports the spoken content.
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