Leader response to error

Assignment Instructions: Leader Response to Error

The Module 2 mini-lecture and resources discussed the complexity of the healthcare environment, individual and system level factors that can contribute to errors, and the importance of leadership in addressing quality and safety. The CANDOR toolkit was also introduced, offering structures and tips for responding to errors. Information from the IHI Modules will also assist you with this assignment. 

Review the AHRQ Implementation Guide for the CANDOR Process: Communication and Optimal Resolution Toolkit.  Skim the Introduction to the CANDOR process,  resources, and checklists.  Watch: Grand Rounds Presentation Video: Communication and Optimal Resolution. This 1-hour video shares examples from The University of Illinois hospital, how they use the CANDOR process, “Just Culture,” and a systems approach for handling medical errors.   

Assignment Scenario: You are a leader in a healthcare organization. You have been informed that a safety event has occurred and a patient required additional testing but will be discharged home soon, with no apparent long-term effects. You have learned that the nature of the error involved an inexperienced nurse who was floated to your unit. IT was reported that the nurse misunderstood some medication orders. The nurse has recently assumed an assignment on the night shift and states they are feeling fatigued and not sleeping well.  They are considering leaving the profession. You are responsible for the initial response to the error. 

1: Introduction: Create an informative title and compose your Introduction (1-2 paragraphs) of the importance of the leader response to errors. 

2. National Steering Committee for Patient Safety: Review the 17 recommended strategies under the four priority areas. Select two strategies from each priority area and discuss how leaders might apply these to improve quality and safety ( no more than two pages).  

3. Leader Response to Error. Review materials from the IHI Modules and CANDOR toolkit. Describe and discuss how you would apply concepts when responding to the above assignment scenario. Create a sub-heading for each of the topics below. Questions can be general.  (no more than four pages)

• Event Investigation and Analysis- address how human factors are determined.
• Response and Disclosure Communication 
• Care for the Caregiver/ Second Victim  
• Organizational Learning 

4: Addressing Emotional Harm: Read article the by Bell et al. which discusses consequences of patient/family emotional harm stemming from preventable medical error.  Reflect upon the described actionable strategies. Review the 20 Things Organizations Can Do Now (Table 3). Select one item that might be applicable to the assignment scenario. Discuss why your team selected this item. ( no more than 2 paragraphs).

5: Conclusion: Write your conclusion (1 paragraph).

Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality (ahrq.gov)

Grand Rounds Presentation Video: Communication and Optimal Resolution (CANDOR) (youtube.com)