Dear All,

Please click on the Case Study Instructions and Repository Tab – and read the Case Analysis Instructions + Review the Learning from Defects Tool_Johns Hopkins before writing your paper. Note the points allotted to each question when answering. Again, I suggest drawing an outline for your paper – headings, sub-headings and then working on the content.

What happened? – flow chart (appendix 1)

Contributory Factors (Why it happened)? Group them into categories and discuss e.g. team work and communication factors, task factors, environmental factors. Which were +ve (helped prevent error) and which were –ve (contributed to errors) appendix -fish bone/cause and effect –

oKey contributory Factors – which ones kept on occurring that lead you to believe these are key… (check sheet followed by histogram/or pareto chart)

Interventions to reduce/prevent this harm – e.g. if one of the key contributory factors is team work and communication – then suggest interventions that are evidence based to improve team work and communication in health care.

How will you know your interventions are working (will work). – Think of ways in which you can evaluate the effectiveness of your intervention.

Hope this helps,