It is A case which is attached and there is 10 question which you have to find the answer by analyzing a case. 1. Start by providing a short 4-6 line synopsis of the key elements of the case – and discuss what kind of incident occurred (week 1). 2. What defenses in the system failed in this case? Can you construct a Swiss cheese analysis of the system defenses and what occurred? 3. What was the culture like in this care setting(s)? What was the leadership like? How do you know? 4. Analyze issues pertaining to human factors, teamwork and communication that arise in this case? Speaking up? Vulnerability around handoffs? 5. To what extent do other concepts like apology, learning, violations, patient engagement & empowerment fit into this case? 6. Is use of any patient safety tools evident? Which ones, could others be used? L. Ginsburg | HLST 3400 – Assignment 2 3 7. Do you see evidence of biases in decision making contributing to the error in this case? (we didn’t discuss this much in class so you may have to read a bit on it)! 8. Does anything else need to be done by those involved in the case? If so, briefly outline what needs to happen and discuss issues or challenges people should be aware of as they try to implement changes. 9. Discuss the extent to which there are systems problems versus accountability problems in this particular case. 10. Discuss any other aspects of the case in the context of course concepts not included in the above questions.