Now that you completed the review of notes on reducing risk, refer to the quality tools and techniques powerpoint (I added into this week’s content again) and do some exploration related to conducting a cause and effect diagram (fishbone).
Instead of you having to search for a scenario I will provide you with 2 different situations for developing a fishbone diagram. Please only do one.
A. An 86 year old male nursing home resident who stays up at night and is usually in the dining room; wandered to a staircase in his wheelchair and fell down 16 steps to his death. He had his wanderguard bracelet on. What happened?
B. A 25 year old nursing home patient with advanced multiple sclerosis was admitted with a Do Not Resuscitate Order and requested that the Physician change the order on admission and several times subsequently. One month later the patient suffered a cardiac arrest on the way to the hospital. He was not resuscitated and expired. What happened?
Consider policies and procedures, methods, materials, training, etc. If you are unable to create a template in word or excel and or are unable to copy and paste into the discussion response, you can manually draw it out and send it to me in an e-mail attachment. Please contact me if you have any questions. It is a good opportunity to use the quality skills you have learned to date.
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