What were the patterns discovered? Under what conditions is it likely that the changing the conditions identified would prevent an actual error from occurring?

The student will complete a Power-Point presentation based on the following objectives:

Examine the safety related literature and web sites.
Examine The Joint Commission’s current Patient Safety Goals and AHRQ’s Patient Safety Indicators.
Develop a working knowledge of the safety indicators.
Analyze the identified issue using the FMEA process for implementation of the current work environment.
Reflect on their learning.

Components of the project and grading criteria:
Identify a breakdown or imminent breakdown in clinical practice – 25 points
Review the class resources for examples that may apply to current practice and describe a high risk situation or risk for error in a case study format.
Identify the type, frequency and repetition of the problem as you can best determine from the literature.
Include reflection on the project including:
What were the patterns discovered?
Under what conditions is it likely that the changing the conditions identified would prevent an actual error from occurring?
highlight in presentation the highest RPN
What error prevention strategies may be applicable for the situations described in order to be successful in risk reduction
Include a slide with 3 selected references or other web links in addition to the IHI