Discuss the chain of events and mistakes that led to death

Assignment Help Management Theories

Reference no: EM133501402

Question 1. Discuss the chain of events and mistakes that led to the death of Robin and her baby. At what point could the pending disaster have been stopped? What processes could be put in place to prevent such an event from occurring?

Question 2. The most significant change that the hospital made was to stop buying enteral feeding solution that came without the tubing attached. Research human factors theory and discuss the human factors issues that arise with tubing misconnections. How can forcing functions like the anticipated move to specialized connectors improve the situation?

Question 3. Glenda Rodgers blames herself for not asking more questions when her daughter was in the hospital. She feels that, as an experienced obstetrical nurse, she should have caught what was going on and been able to put a stop to it. Yet stories of healthcare professionals being unable to stop adverse events from happening to their own family members are common. Why do you think that healthcare professionals may feel helpless to prevent errors when they become a patient or have a family member who is a patient?

Question 4. Research the concept of just culture, and discuss how you think it applies in this case. What should the consequences have been for the nurse who caused the tubing misconnection?

Question 5. As the rollout of new tubing connector standards began, the American accrediting agency The Joint Commission issued Sentinel Event Alert No. 53 to help healthcare facilities deal with the transition. Why do you think The Joint Commission considered this to be necessary? What unintended consequences should healthcare professionals be vigilant for when changes take place in practice and technology?

Which of the core competencies for health professions are most relevant for this case? Why?

Reference no: EM133501402

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