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Complete question 1 in 500 words.
Complete question 2 in 900 - 1000 words.
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Question 1
Objective: To practice identifying different types of errors described in Reason's Swiss cheese model.
Instructions:
•Consider the following scenario: In Florida, Clara, an active 94-year-old great-grandmother who still
worked as a hospital volunteer two days a week, was admitted to the hospital for a bowel obstruction.
She and her family, along with nurses from the hospital, said that there were too few nurses to check on
her during the night when her eldest son went home to sleep for a couple of hours. Clara called the
nurses to help her use the bathroom but when no one came, she climbed over the bed railing. Still
groggy from surgery 20 hours earlier, Clara fell to the floor and broke her left hip. She died two days
later during surgery to repair the hip fracture. "It was just too much for her," said her grandson. "For
want of one nurse, she died" (Gibson and Singh 2003, 101).
•Review the following list of latent errors, active errors, and preconditions that could have contributed
to the event described in this scenario.
–Absence of one nurse and one nurse aide because of illness that night
–Clara's advanced age not taken into consideration by caregivers
–Unavailability of staff to fill in for the two people calling in sick
–Falls risk assessment not complete on patient's chart
–Decision to upgrade computed tomography scanner over purchasing safer patient beds
–Lack of training for nurses about specialized needs of elderly patients, especially related to their
responses to medications
–The departure of Clara's son
–Consistent scheduling of the night shift with minimum staff needed on the unit
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–Bioengineering's skipping of last month's preventive maintenance check on the call light system
(because the department was six weeks behind on its work)
–Admission of three new patients to this unit from the emergency department between 7:00 pm and
10:00 pm
–Falls precautions not implemented for this patient
Write the errors and risk factors in column 2 beside the appropriate category. (500 Words).
Answers:
Category/Type of Failure
Latent errors at the level of senior
decision-makers
Latent failures at the level of frontline
management
Error
The less obvious organizational or design flaws contribute
to errors occurring or permit them to damage people
(Wiegmann et al., 2022). The choice to upgrade the
computed tomography scanner rather than buy safer
patient beds in the scenario can be seen as a latent error
at the level of the decision-makers. The choice might have
taken money away from buying fall-resistant, safer patient
beds. The scenario has made clear how important it is to
put patient safety ahead of other considerations like costcutting or technological advancement.
A latent failing at the level of frontline management is the
absence of training provided to nurses regarding the
unique needs of elderly patients, particularly in relation to
how they respond to medicines (Wiegmann et al., 2022). If
the nurses had received proper training, Clara would have
received better treatment. The knowledge to deliver
specialized care to particular patient populations requires
ongoing training for nurses in order to keep them abreast
of the most recent best practices.
A latent failure at the level of frontline management was
also demonstrated by the bioengineering department's
failure to perform the call light system's preventive
maintenance inspection last month due to a backlog. It is
essential to do preventive maintenance checks on
equipment to ensure it is operating properly and avoid
breakdowns that could result in unfavorable outcomes. To
ensure that patients are safe, the department needs to
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create a system that prioritizes preventative maintenance
(Wiegmann et al., 2022).
Circumstances or conditions present
when the patient's accident occurred
Active errors associated with this event
The departure of Clara's son, the admission of three new
patients to this unit from the emergency department
between 7:00 pm and 10:00 pm, and consistent
scheduling of the night shift with the minimum staff
needed on the unit are preconditions that contributed to
the event. Two nurses and one nurse assistant were also
absent due to illness that night, and no staff was available
to cover for the two people calling in sick and the
departure of Clara's son. These circumstances might have
contributed to a staff shortage that prevented Clara from
rece...