work on Tooling up to prevent never events. Northfield: Healthcare Purchasing News.

  1. Assignment Expectations:
    1. Address concept A and B in about 150 words each.
    2. You will be graded on how well you demonstrate knowledge and understanding of the concept, and critical thinking pertaining to the applicability of the concept to your professional practice. Points awarded will follow breakdown below.
    3. You will neither be required to, nor graded on responses to your peers. One posting will suffice.
  2. The Assignment: Given the readings and assignments in the course, identify and discuss two concepts or lessons learned that you believe will be most applicable to your professional discipline.
  3. Concept A (points 10/20):
    1. Identify /define (points 4/20): ……
    2. Your professional discipline: ……..
    3. How applicable (points 6/20): ……
  4. Concept B (points 10/20):
    1. Identify /define (points 4/20): ……
    2. Your professional discipline: ……..
    3. How applicable (points 6/20): ……

All information in the postings can be shared by all for the betterment of your project.

Required Reading

Cantrell, S. (2016). Tooling up to prevent never events. Northfield: Healthcare Purchasing News.

Dimsdale, J. E. (2017). Assuring quality health care outcomes: lessons learned from car dealers? Patient Related Outcome Measures8, 1–6.

Gleeson H, Calderon A, Swami V, et al. (2016). Systematic review of approaches to using patient experience data for quality improvement in healthcare settings. BMJ Open 2016;6:e011907.

Ha, C., McCoy, D. A., Taylor, C. B., Kirk, K. D., Fry, R. S., & Modi, J. R. (2016). Using Lean Six Sigma methodology to improve a mass immunizations process at the United States Naval Academy. Military Medicine, 181(6), 582-588.

Health and medicine – health organization and management; University of Malta details findings in health organization and management (continuous quality improvement in a Maltese hospital using logical framework analysis). (2017). Health & Medicine Week, , 5215.

Kozusko, S. D., Elkwood, L., Gaynor, D., & Chagares, S. A. (2016). An innovative approach to the surgical time out: A patient-focused model. Association of Operating Room Nurses. AORN Journal, 103(6), 617-622.

Lee, S. L. (2017). The extended surgical time-out: does it improve quality and prevent wrong-site surgery?. Issues2016.

Lee, T. (2016). Lean and Six Sigma: these process improvement strategies from the business world can be used effectively in your office. Contemporary OB/GYN61(6), 28-35.

Mudiwa, L. (2016). Group to use Lean Six Sigma to meet ED targets. Irish Medical Times, 50(31), 3.

Mills, E. (2016). The WakeWings journey: Creating a patient safety program. Association of Operating Room Nurses.AORN Journal, 103(6), 636-639.

Nguyen, M. C., & Moffatt-Bruce, S. D. (2016). What’s New in Academic Medicine? Retained surgical items: Is “zero incidence” achievable?. International Journal of Academic Medicine2(1), 1.

Surgery – discectomy; investigators from Oregon Institute of Technology target discectomy (hospital charges associated with “never events” comparison of anterior cervical discectomy and fusion, posterior lumbar interbody fusion, and lumbar laminectomy to total joint. (2016). Biotech Week,, 399.

Kamiya, Y., Ishijma, H., Hagiwara, A., Takahashi, S., Henook A.M., Ngonyani, Samky, E. Evaluating the impact of continuous quality improvement methods at hospitals in Tanzania: a cluster-randomized trial. Int J Qual Health Care 2017; 29 (1): 32-39.


Agency for Health Care Research and Quality (n. d.). Never events.

The Joint Commission:

Module 2

Required Reading

Adirim, T., Meade, K., & Mistry, K. (2016). A New Era in Quality Measurement: The Development and Application of Quality Measures. Pediatrics, e20163442.

Banahan, B., Hardwick, S., Noble, S., & Clark, J. (2016). Using pharmacy quality measures in medicaid drug utilization review programs. Research in Social and Administrative Pharmacy, 12(4), e5-e6.

Büchtemann, D., Kästner, D., Warnke, I., Radisch, J., Baumgardt, J., Giersberg, S., . . . Rössler, W. (2016). Hospital utilization outcome of an assertive outreach model for schizophrenic patients – results of a quasi-experimental study. Psychiatry Research, 241, 249-255.

Goldberg, S. (2016). Utilization review under fire in state high court. Business Insurance, 50(9), 3.

Mathias, P. C., Conta, J. H., Konnick, E. Q., Sternen, D. L., Stasi, S. M., Cole, B. L., . . . Dickerson, J. A. (2016). Preventing genetic testing order errors with a laboratory utilization management program.American Journal of Clinical Pathology, 146(2), 221-226.

Mospan, C. M., & Alexander, K. M. (2017). Teaching drug utilization review skills via a simulated clinical decision making exercise. Currents in Pharmacy Teaching and Learning

Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from:

Prime therapeutics is certified for NCQA utilization management and health information products – pharmacy benefit information. (2017, Jan 27). PR Newswire

Science; researchers at Singapore general hospital discuss findings in science (effectiveness of a multidisciplinary home-based medication review program in reducing healthcare utilization among older adult Singaporeans). (2017). Clinical Trials Week, , 908.

Module 3

Required Reading

Brad Lamm’s becomes first intervention, family class and case management group to receive Joint Commission’s “gold standard”. (2017). PR Newswire

Grover, C. A., Crawford, E., & Close, R. J. H. (2016). The efficacy of case management on emergency department frequent users: An eight-year observational study. The Journal of Emergency Medicine, 51(5), 595-604.

Gowing, A., Dickinson, C., Gorman, T., Robinson, L., & Duncan, R. (2016). Patients’ experiences of a multidisciplinary team-led community case management programme: A qualitative study. BMJ Open, 6(9), e012019.

Huntley, A. L., Johnson, R., King, A., Morris, R. W., & Purdy, S. (2016). Does case management for patients with heart failure based in the community reduce unplanned hospital admissions? A systematic review and meta-analysis. BMJ Open, 6(5), e010933.

Kim, K. B., Kim, M. T., Lee, H. B., Nguyen, T., Bone, L. R., & Levine, D. (2016). Community health workers versus nurses as counselors or case managers in a self-help diabetes management program. American Journal of Public Health, 106(6), 1052-1058.

Moise, I. K., & Mulhall, P. F. (2016). Providers’ perspectives on case management of a healthy start program: A qualitative study. PloS One, 11(5), e0154668.

Moreo, K., Moreo, N., Urbano, F. L., Weeks, M., & Greene, L. (2014). Are We Prepared for Affordable Care Act Provisions of Care Coordination? Case Managers’ Self-Assessments and Views on Physicians’ Roles. Professional Case Management. 19(1), 18-26.

Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from:

The PLOS ONE Staff. (2016). Correction: Providers’ perspectives on case management of a healthy start program: A qualitative study. Plos One, 11(6), e0157803.

Module 4

Required Reading

Dastjerdi, H. A., Khorasani, E., Yarmohammadian, M. H., & Ahmadzade, M. S. (2017). Evaluating the application of failure mode and effects analysis technique in hospital wards: A systematic review. Journal of Injury and Violence Research, 9(1), 51-60.

Franck, L. S., Gay, C. L., Cooper, B., Ezrre, S., Murphy, B., Chan, J. S., . . . Meer, C. R. (2017). The little schmidy pediatric hospital fall risk assessment index: A diagnostic accuracy study. International Journal of Nursing Studies, 68, 51-59.

Goodrum, L., & Varkey, P. (2017). Prevention is better: The case of the underutilized failure mode effect analysis in patient safety. Israel Journal of Health Policy Research, 6(1)

Magnezi, R., Hemi, A., & Hemi, R. (2016). Using the failure mode and effects analysis model to improve parathyroid hormone and adrenocorticotropic hormone testing. Risk Management and Healthcare Policy, 9, 271-274.

McElroy, L. M., Khorzad, R., Nannicelli, A. P., Brown, A. R., Ladner, D. P., & Holl, J. L. (2016). Failure mode and effects analysis: A comparison of two common risk prioritisation methods. BMJ Quality & Safety, 25(5), 329.

Ofek, F., Magnezi, R., Kurzweil, Y., Gazit, I., Berkovitch, S., & Tal, O. (2016). Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards. Israel Journal of Health Policy Research, 5(1)

Pennsylvania patient safety authority focuses on data, standardization of reports, the patient safety advisory, education and its collaboration efforts in its 2015 annual report: Highlights include implementation of 28 principles to standardize reporting, an increase in facility engagement and a reduction in catheter-associated urinary tract infection rates. (2016, ). PR Newswire

Reliability engineering; new reliability engineering findings has been reported by investigators at stavanger university hospital (on the need for revising healthcare failure mode and effect analysis for assessing potential for patient harm in healthcare processes). (2016). Journal of Engineering, , 1563.

Sussman, R. G., Schatz, A. R., Kimmel, T. A., Ader, A., Naumann, B. D., & Weideman, P. A. (2016). Identifying and assessing highly hazardous drugs within quality risk management programs. Regulatory Toxicology and Pharmacology : RTP, 79 Suppl 1, S11-S18.