This RCA case study was modified from a sentinel event reported in the following article: Smetzer, J., Baker, C., Byrne, F. D., & Cohen, M. R. (2010). Shaping systems for better behavioral choices: Lessons learned from a fatal medication error. Joint Commission Journal on Quality and Patient Safety, 36(4), 152-163.
Short videos are used in this non-linear module to introduce students to the case, and to give them the opportunity to view interactions between the key players.
This project was selected for the following poster presentation:
Making it Real: Fostering Inquiry-Based Learning in a Virtual Environment
Mar 1, 2014 Poster Presentation: Emswiller Interprofessional Symposium, Richmond, VA
This poster illustrates the use of innovative technologies to create an interactive online scenario addressing patient safety and quality. The scenario is based on a sentinel event published in the Joint Commission Journal on Quality and Patient Safety (Seltzer et al., 2010) and was modified to include features that (1) promote awareness of multiple system factors as contributors to an event; (2) enhance appreciation of interprofessional collaboration by including information from staff nurses, nurse managers, physicians, pharmacists, and risk management; and, (3) enhance student engagement using a non-linear approach to information delivery and visualization of the emotional implications of an event in ways that are not possible in text-based scenarios. The scenario incorporates principles of Universal Design for Learners and is accessible to those with visual or hearing impairments. It is available on the Multimedia Educational Resource for Learning and Online Teaching website (merlot.org), with an average review of 5 stars.
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