HA3110D – Quality Improvement and Risk Management
After viewing the IHI’s “What Happened to Josie?,” one of the most compelling hospital error cases resulting in change, reflect back on Chapter 1’s National Quality Strategy Six Priorities.
Of these four a) patient safety, b) person-and family-centered care and c) communication and (d) coordination of care, discuss:
1.Identify safety measures that were missed throughout Josie’s hospitalization that contributed to her sudden change in condition.
2.Which factor, communication, or coordination of care do you consider the most crucial factor in Josie’s case? Why? Support your response.
3.What actions might have been taken to prevent Josie’s death?
4.From your learning, explain how reliability science could have been applied to prevent Josie’s death.