HCA 410 It’s Hard to Kill a Healthy 15 Year Old The Story of Lewis Blackman Case Analysis of Medical Procedure (Patient Safety)

Instructions: First read the case you have chosen from the case repository on blackboard thoroughly AND review the “Learning from Defects” tool provided. This tool was developed and adapted by the Quality and Safety Research Group led by Professor Pronovost et al to help health care providers identify and learn from defects utilizing a systems approach. The contributory factors framework helps providers gain a deeper appreciation of harm as it occurs usually due to breakdown of systems (multiple factors). It steers clear of blame and punitive behavior and encourages teams to focus on learning.

Attempt All four questions in response to the case provided below as though you are part of the team investigating. What happened, why (contributory factors), key contributory factors that led to the event.

Be sure to categorize your contributory factors into patient factors, caregiver factors, task, teamwork and communication etc. Please use QI tools such as flow chart, cause and effect/fishbone and pareto charts to justify your interventions. These charts should be part of your appendices. Suggest interventions so that such events will not occur in the future (be sure that the interventions you suggest address the key contributory factors). Then provide measures that you will assess to know if your suggested interventions are working. Assume that you have implemented your recommendations. How will you know that these worked to reduce/eliminate risk? What measures would help confirm improvements. Please include an abstract as your first page and include titles and sub-titles (e.g. what happened, why (contributory factors), key contributory factors etc.

Try to be objective and use facts from the case. It is recommended that you take time reading the case and ascertain key contributory factors prior to suggesting any intervention. You may use additional sheets of paper to make rough notes, provide your rationale for choices/additional descriptions, flow chart etc. You should prepare an outline first for your case analysis. Feel free to visit your instructor during office hours for any questions that you may have concerning this assignment.

Format and page length: APA 6.0 format, and between 6-8 pages excluding appendices and cover page– see syllabus for other details.

Grading Rubric: Your responses will be graded on the basis of clarity of thought, originality, accuracy and specificity of content, and the approach utilized in analyzing the defect and providing recommendations.

Possible maximum points by question:

Question # 1 (10 points)
Question # 2 (40 points)
Question # 3 (40 points)
Question # 4 (10 points)
Total = 100 points

Use at least one of the following charts (in the appendix)


Course: HCA 410 Quality Improvement Methods in Health Care
School: Saint Leo University

  • 15/06/2017
  • 35
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