Exercise 13.1: Identifying Types of Errors. Read the case scenario on page 266. Review the list of errors that is provided and classify them according to the categories in the table on p. 267. Using Word, create a table like the one on page 267 to record your responses.

Objective: To practice identifying different types of errons described in Reasoris swis checse model. Instructions: - Consider the following scenario: In Florida, Clara, an active 94.ycar-eld great-grandmother who still worked as a hospital volunteer two day a weck, was admitted to the hospital for a bowel obstruction. She and ber family, along with murses from the hospital, said that there were too few nurses to check on her during the night when her eldest son wens home to sleep for a couple of hours. Clara called the nunes to help ber use the buthroom but when no one came, she climbed over the bed railing. Still groggy from surgery 20 hours earlicr, Clara fell to the floer and broke her left hip. She died two dyys later during surgery to repuir the hip fracture. "Ir was just too much for her," said her grandwon. "For want of one nurse, she died" (Gibson and Singh 2003, 101). - Revicw the following list of latent errors, active errons, and preconditions that could have contributed to the event described in this scenario. - Abeence of one nurse and one nurse aide because of illness that night - Clara's advanced age not taken into consideration by caregivers - Unavailability of saff to fill in for the two people calling in sick - Falls risk asessment not complete on patient's chart Erercise 13.2 - Decision to upgrade computed tomography seanner over parchaing 0Nicctive: To practice addressing the qucations in The foint Commision sefer patient beds "Framework for Conducting a Root Cause Andyus and Motoo Finn". - Lack of training for nures about specialized needs of elderly patiknt, epecially related to their responses to medications fnatructions: - The depurture of Clara's mon - Consistent wheduling of the night shift with minimum staff needed on the unit - Bioengincering's skipping of last month's preventive maintenance check on the call light wytem (because the department was six weeks behind on its work) - Admision of three new patients to this unit from the emergency department between 7.00 pm and 10.00pm - Falls precautions not implemented for this putient Write the crrors and riak factors in column 2 beside the appropriate category. Objective: To practice identifying different types of errons described in Reasoris swis checse model. Instructions: - Consider the following scenario: In Florida, Clara, an active 94.ycar-eld great-grandmother who still worked as a hospital volunteer two day a weck, was admitted to the hospital for a bowel obstruction. She and ber family, along with murses from the hospital, said that there were too few nurses to check on her during the night when her eldest son wens home to sleep for a couple of hours. Clara called the nunes to help ber use the buthroom but when no one came, she climbed over the bed railing. Still groggy from surgery 20 hours earlicr, Clara fell to the floer and broke her left hip. She died two dyys later during surgery to repuir the hip fracture. "Ir was just too much for her," said her grandwon. "For want of one nurse, she died" (Gibson and Singh 2003, 101). - Revicw the following list of latent errors, active errons, and preconditions that could have contributed to the event described in this scenario. - Abeence of one nurse and one nurse aide because of illness that night - Clara's advanced age not taken into consideration by caregivers - Unavailability of saff to fill in for the two people calling in sick - Falls risk asessment not complete on patient's chart Erercise 13.2 - Decision to upgrade computed tomography seanner over parchaing 0Nicctive: To practice addressing the qucations in The foint Commision sefer patient beds "Framework for Conducting a Root Cause Andyus and Motoo Finn". - Lack of training for nures about specialized needs of elderly patiknt, epecially related to their responses to medications fnatructions: - The depurture of Clara's mon - Consistent wheduling of the night shift with minimum staff needed on the unit - Bioengincering's skipping of last month's preventive maintenance check on the call light wytem (because the department was six weeks behind on its work) - Admision of three new patients to this unit from the emergency department between 7.00 pm and 10.00pm - Falls precautions not implemented for this putient Write the crrors and riak factors in column 2 beside the appropriate category