Midterm Assignment Case Study

For this assignment, students will review the case of an adverse event—the story of Brianna Cohen (also available in the Online Library)

1. Briefly describe the incident (in 1 page or less)
2. Describe the points at which failures occurred
3. Identify the factors at various levels of the system that contributed to those failures

Students are encouraged to use the “Investigating a defect” tool described in Dr. Pronovost’s lecture and reading.

The midterm paper will be graded on the basis of 100 possible points which will be allocated according to the following criteria:

  • Description of the problem (20 points)
  • Identification of the points at which failures occurred (20 points)
  • Contributing factors (40 points)—- 5 points for identifying possible/probable factors at each of the following levels:
    –Patient/family
    –Task
    –Individual provider (physician, nurse, pharmacist, etc.)
    –Team
    –Training and education
    –Information Technology
    –Local environment (e.g., organizational, unit, division, department)
    –Institutional environment
  • Reasoning and clarity of presentation (20 points)

I have attached 3 PDF files of the this assignment please look at them carefully in order to do it.

 
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