Introduction to Healthcare Quality Management, Fourth Edition by Patrice L. Spath;Kenneth A. DeVane;

Author:Patrice L. Spath;Kenneth A. DeVane; [Spath, Patrice L.]
Language: eng
Format: epub
ISBN: 9781640553620
Publisher: Independent Publishers Group
Published: 2022-08-13T00:00:00+00:00

The RCA team for the wrong-site surgery event includes the people directly involved in the procedure—the surgeon, anesthesiologist, surgical nurses, and surgery scheduling clerk—and the managers of the admission and surgical areas. The team’s first task is to determine what happened by collecting and inspecting physical evidence (e.g., equipment, materials, safety devices) and reviewing documentary evidence (paper or electronic media). The team also asks the people directly and indirectly involved in the event to provide their perspectives. These discussions may occur in a team meeting, or people may be interviewed individually. Ultimately, the team develops a picture of the event and creates a high-level flowchart to illustrate the steps leading up to it (exhibit 8.12).

EXHIBIT 8.12 High-Level Flowchart of Event

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