Hospital D uses an electronic system (application) to record events or incidents occurring within the hospital system. Currently, 40% of the events reported in the system need to be revised due to inaccurate initial categorization, which doubles the amount of work related to this function. Furthermore, additional notes from a prior internal interview of nurses indicate that between 40-50% of the incidents that occur are not being reported in the system at all because of misperceptions of what constitutes patient harm.

 Resource from OIG: HOSPITAL INCIDENT REPORTING SYSTMS DO NOT CAPTURE MOST PATIENT HARM  https://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf 

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Tasks:

• Use root-cause analysis to explore one of the issues: (1) 40-50% incidence reports not being reported at all; or (2) 40% of the incidents reported in the system are not categorized accurately and need to be analyzed and revised. (40 points)
• What other individuals would you want to include as part of your analysis and why? (nurses, other clinicians, IT) (10 points)
• Explain potential consequences of non-reporting or improper reporting of events in terms of compliance, patient safety, and productivity/efficiency aspects. Use the textbook and DHHS report as one of the resources. In addition, use a peer-reviewed article to support your answer. (20 points)