Assignment Task:
As a nurse leader, it is brought to your attention that a patient who is two days post-op has developed a UTI. The surgeon blames the nursing staff and insists that only experienced nurses be assigned to care for his patients. As you respectfully listen to his concerns, you successfully defuse conflict and present a plan to investigate what happened.
Before reading on, pause and consider which step you might take next.
To begin your investigation, you decide to meet with the nurse manager to determine what is known about the incident. The nurse manager relates that the staff nurse assigned to the patient pre-op received an order to insert a Foley catheter prior to sending the patient to the OR. She was administering medications to her four other patients and went to review the chart to prepare the patient for surgery. She discovered the new order for the Foley had been added at some point between her initial review of the orders and now. The charge nurse informed the OR was ready for the patient.
The nurse went to gather the equipment to insert the Foley and discovered there were no more kits on the unit. She dashed to another unit but they did not have any kits. She went up to the 3rdfloor to check in the ICU. They did not have any kits but had the supplies. The nurse quickly gathered supplies and rushed back to her patient. During the procedure, the nurse was interrupted by the transport team ready to move and transfer the patient. The transport team complained that the surgeon was waiting and the patient should have been ready. One of the other nurses called in to say that other patients were looking for their nurse. The nurse worked as quickly as she could to get her patient down to the OR and get back to see to the needs of her other patients.
1. Incorporate a reactive systems assessment. Complete a root-cause analysis. Using the case study listed in the Supporting Materials section, complete a root-cause analysis. Need Assignment Help?
- Describe the tool.
- Explain the purpose or use of that tool.
- Describe how the selected tool is used in practice.
2. Determine a quality improvement model for an evaluation of outcomes.
- Explain how the root-cause analysis taken from the case study applies to the quality improvement process within the framework of your chosen quality improvement model.