Critical Action Items: Systematic Analysis of a Medical Error |
Assessed initial vital signs |
95% |
Secured airway |
95% |
Appropriate ACLS protocol |
80% |
Asked for patient history |
55% |
Wash hands |
45% |
Obtain focused PE |
95% |
Recognize medical error/adverse event |
100% |
Identify contributors of the medical error |
100% |
Identify strategies to decrease probability of this error |
100% |
Generate a root cause analysis |
100% |
Critical Action Items: Interprofessional Hand-Off |
Provided appropriate illness severity |
55% |
Patient summary is concise and relevant |
55% |
Provided action plan with clear instructions |
100% |
To do list provided |
100% |
Provided situation awareness – plan for what might happen |
100% |
Made efforts to clarify code status with patient (does not align with IPASS) |
40% |
Allowed receiver to synthesize and summary |
95% |
Allowed receiver to ask questions |
100% |
Introduced himself/herself and explained roles |
80% |
Critical Action Items: Safe Discharge |
Include patient as a full partner in the discharge process |
95% |
Identified barriers to care |
50% |
Reviewed medication regimen |
95% |
Highlight warning signs and problems (hypoglycemia or hyperglycemia symptoms) |
95% |
Discuss follow up appointments |
95% |
Educate the patient in plain language about condition (no medical jargon used) |
100% |
Assess patient understanding/patient teach back (asked patient to repeat back) |
70% |
Provide information in small chunks and repeat key pieces of information |
95% |