In a new role within your organization, you have been asked to prepare a memo for the executive team on the organization’s current status of quality, medical errors, and safety. You may use your current organization or one where you desire to work in the future for this assessment.

This Assessment requires submission of one (1) document, Save your file as OM001_firstinitial_lastname (for example, OM001_J_Smith).

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Before submitting your Assessment, carefully review the rubric. This is the same rubric the assessor will use to evaluate your submission and it provides detailed criteria describing how to achieve or master the Competency. Many students find that understanding the requirements of the Assessment and the rubric criteria help them direct their focus and use their time most productively.


Access the following to complete this Assessment:

To begin the Assessment, read:

To complete the Assessment, create a memo to the executive board of your organization that addresses the following:

  1. The three key objectives and impacts of the Institute of Medicine’s (IOM) To Err Is Human: Building a Safer Health System and the follow-up report Crossing the Quality Chasm, paying particular attention to the components of these reports and how they affect your organization.
    1. Describe how the objectives and impacts of these important reports might influence the goals, mission, and values of your organization.
  2.  Analyze an adverse safety event that became an impetus for systems changes related to patient safety as follows:
    1. Describe the event and its effects on key persons involved.
    1. Explain the systemic failure that allowed the event to occur.
    1. Explain system changes that were made as a result of this event as well as two positive outcomes due to those changes.
    1. Explain how the adverse event you described, the related systemic failure, and the changes that resulted affected operational procedures at your organization.
  3. Identify at least two patient safety goals at your organization and briefly describe two different organizations that specialize in the area of patient safety that you selected, including their mission, purpose, and values; explain how their resources can be used to achieve your organization’s safety goals.
  4. Identify at least two risks to medical, clinical, and other organizational staff as second victims when medical errors occur. Recommend two specific strategies your organization can implement to assist its internal stakeholders to cope when medical errors do occur.
  5. Evaluate the statement “those who make errors that harm patients are themselves victims”, including pros and cons of this statement in relation to the industry as a whole and your organization in particular.
  6. Talk to a patient safety officer or patient safety nurse at your facility. Then give a brief description of the patient safety officer or patient safety nurse you interviewed and explain how sentinel events are approached from a systems perspective. Then, explain how the approach might have changed as a result of the COVID-19 pandemic. Finally, explain any insights you gained from the conversation.

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