Executive Summary to CEO template 07-09-22 (1)
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Executive Summary to the CEO
Your Name
University of Arizona Global Campus
HCA 460: Health Care Administration Capstone
Instructor's Name
Date (spelled out: January X, 20XX)
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WRITING AN EXECUTIVE SUMMARY
for help understanding the purpose of this type of writing.
Note that the sample on this resource is much shorter than your assignment, so take the general advice but
follow this template to create an assignment that meets your instructor’s requirements.
2
Dosage Management
A patient who had been discharged home on heparin due to previous blood clots experienced an overdose
dose as a result of lapses in the established processes and standard workflows established by our facility,
as detailed in the following Executive Summary. New processes and their results will be outlined in this
summary and given to the whole workforce.
Part 1: The Sentinel Event
A 66-year-old woman presented to the ER on Friday, January 21, 2021, complaining of
abdominal discomfort. According to the record review performed by the case manager, the
female patient just had a hip replacement and has a history of clots. The patient was on a
Heparin regimen.she used a blood thinner before her ERAs presentation to avoid a potentially
fatal blood clot As I start asking the patient about her symptoms, she turns to the side and
throws up.I saw what looked like coffee grounds in the patient's vomit while I was helping them,
and my clinical judgment told me that they had probably overdosed on heparin. I immediately
contacted my supervisor, and together we conducted a thorough assessment of patients,
including her medical records and history, and spoke at length with the member and her family.
The member was not seriously hurt and is making a complete recovery here.The following
parties were informed of the mistake, and the relevant authorities have been contacted to
provide their assistance to our establishment.They are now looking into what went wrong. The
following organizations will report back to us with thorough data that may be used to inform both
preliminary and final procedures and mitigation strategies. The FDA of the United States of
America,The Food and Drug Administration (FDA) is an agency created by law to safeguard the
public's health via the regulation of foods, pharmaceuticals, and other items intended for human
and animal use. The Joint Commission's National Patient Safety Goal (NPSG): The National
Patient Safety Goals were established with that end in mind. The objectives are centered on
addressing issues related to patient safety in medical settings. Pharmaceutical Companies in
the United States The National Formulary: a compendium of medication information including
chemical make-up, production details, and recommended doses
Part 2: Root Cause Analysis (Fishbone Diagram)
(Note: This is a sample. Do not replicate the contents of this exact diagram. Right click on the
image and select CUT from the list to remove it.)
3
For this section, you will create the CQI Tool (Fishbone), complete the tool, copy (or take
a screenshot of) the completed work, and paste the completed diagram here. If you are
unfamiliar with the Fishbone, please refer to the
Using Quality Improvement Methods for
Evaluating Health Care
article by Siriwardena (2009). In addition, as a learning resource, the CQI
tool listed below is hyperlinked to the Institute for Health Care Improvement website, which
discusses and illustrates an example of the Fishbone.
Tools: Cause and Effect Diagram
Part 3: Root Cause Analysis Report
In this section, you will create a root cause analysis.
In this first paragraph, you will
identify the data elements you would collect to determine the cause and give your rationale for
choosing these data elements. Data elements are the numbers that are used to identify and
track the happenings within the organization. For example, if the sentinel event occurred due to
insufficient staff on duty at the time, the number of staff members on duty is a data element.
Probable Cause
Next, identify the probable cause. This may include process failure, human error, cultural
biases, policy error, systems error, technology failure, or some other issue that may have
contributed to your sentinel event. Include any or all of the following subsections in completing
the probable cause portion of your report.
Human Factors
What human factors were relevant to the outcome?
Hint
: Ctrl + Click
ACADEMIC VOICE
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