CASE Study: The purpose of this assignment is to evaluate the value of health information technology in the prevention and detection of errors, as well as analysis of unintended consequences and human factors through quality improvement strategies.

1. Apply one of the Quality Improvement Models discussed in the course, or choose an approach from the literature, or the one used in your workplace to analyze the case.

   1. Summarize the case in one paragraph, highlighting the role of HIT.

   2. Describe briefly the model chosen for the analysis.

      1. Provide a rationale for using the selected model over other options.

   3. Follow the model steps and processes to identify the quality, safety, security, privacy, and unintended consequences issues in the case.

   4. List interprofessional team members who may be consulted on this process and their expected role.

2. Design strategies for your workplace to mitigate the issues identified from the case.

   1. Provide at least one visual of the process and proposed changes (i.e., flow chart, process map, data quality, pareto chart, control chart, data visualization).

   2. Identify changes if needed to policies, EHR, equipment, and other HIT applications.

   3. Create a communication/transition plan.

   4. Develop a staff education plan on changes.

      1. What change theory would be best for this program?

      2. What educational deliver method (s) would be most effective?

   5. Compose metrics for evaluating the plan in each of the learning domains:

      1. Cognitive

      2. Psychomotor

      3. Effective

   6. Reflect on the ramifications of criminalizing the nonintentional reporting of mistakes on your own advanced practice, the nursing profession, and Quality Improvement practices.

3. Submit the written report in APA 7th ed. format, 10-12 pages in length, not including title page, the 1-page reflection and references. Use headers to distinguish the sections of the paper.

Solution

The RaDonda Vaught case is about a tragic medication error that happened in 2017 December at Vanderbilt University Medical Centre where the nurse by the name RaDonda Vaught administered vecuronium by mistake and the drug is a paralytic agent rather than administering Versed an anti-anxiety medication to the patient Charlene Murphey. This error resulted in Muphey’s brain death and the subsequent death after resuscitation attempts had failed (Harrington, 2023). The charge that was given to Vaught was massive negligence and neglect homicide and they highlighted the significant issues that are related to health information technology (HIT) specifically being dependent on automated medication dispensing cabinets together with a lack of effective safety protocols. This case underscores the systemic vulnerabilities in healthcare settings where there is a possibility of technology contributing to errors more so when compounded by organizational pressures and inadequate training…………..

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