BACKGROUND: Take some time to research the Patient Safety and Quality Improvement Act of 2005. This landmark piece of legislation continues to be a critical law for health care managers to follow. While promoting patient safety and quality of care, this act also caused (and continues to cause) some tension between improving the quality of care provided with acknowledging and reporting responsibility for error in the health care settings.

ASSIGNMENT: Review the three types of patient safety events that are reportable under the Patient Safety and Quality Improvement Act, and locate an example of such an event that has occurred under one of the three reportable categories.

Then:

1. Clearly summarize the patient safety event. What (specifically) happened, what were the circumstances of the event, and what person(s)/position(s) was/were deemed to be at fault?

2. What stakeholders were involved? What was the role of each? Often, these events involve several stakeholders, so consider all parties carefully.

3. Articulate a specific plan for preventing this type of patient safety event from happening again. What (specifically) must change, be done differently, not be done, etc.?

4. On the last page of your assignment, draft an email to communicate the prevention plan to your employees. Be clear and concise in what your expectations are, and who is responsible for all parts of the plan’s implementation and monitoring.

3-5 PAGES*

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