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under reporting of incidents & inaccurate categorization

Group 9 Performance Improvement Final

Lynda Pham

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Nelly Secer

Nathalie Sper

Rosalina Dorvilus

Week 8: Risk Management – Event Reporting

Hospital D uses an electronic system (application) to record events or incidents occurring within the hospital system. Currently, 40% of the events reported in the system need to be revised due to inaccurate initial categorization, which doubles the amount of work related to this function. Furthermore, additional notes from a prior internal interview of nurses indicate that between 40-50% of the incidents that occur are not being reported in the system at all because of misperceptions of what constitutes patient harm.

Issue: underreporting of incidents & inaccurate categorization

QI Toolbox Techniques used:

Unstructured brainstorming: all members generate ideas as they come to mind

Evaluating all potential factors (causes) of the problem

Identifying & categorizing factors that contribute to the problem

3

Brainstorming

Root Cause Analysis (RCA)

Cause & Effect diagram (Fishbone diagram)

Our Process:

We used RCA to identify proximate causes and used the cause-and-effect diagram (fishbone diagram) to categorize those factors as well as identify any underlying causes that may have contributed to the problem (underreporting of incidents).

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