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These four proposed solutions were assessed for effort and impact and then plotted with corresponding numbers (Figure 1), clearly showing that using bar codes on patient ID bands and charts would be the obvious first option. Implant a radio frequency identification (RFID) tag under the skin of patients and attach to each medical chart for matching at each transfer point.Bar code patient ID bands and charts and match before transport.Train every employee on patient identification policy.Create a policy for matching patient ID to chart ID at every point in transfer.The event was investigated, and several proposed solutions surfaced: This precipitated a change in treatment prior to giving the patient a medication to which they were highly allergic. It was only when the faxed chart materials were received that a nurse recognized that the transported chart copies were for another LTACH patient on the same unit. Once at the emergency room, the patient was treated according to the presenting symptoms and history included in the photocopied chart pages. The nursing staff photocopied portions of the chart for transport with the patient, and additional portions of the chart were faxed to the emergency toom after the patient had departed the LTACH.

An ambulance service was dispatched to transport the patient stat.

Solutions falling into the upper left-hand quadrant will yield the best return on investments and should be considered first.ĭuring admission to a long-term acute care hospital (LTACH), a patient destabilized and suffered cardiac arrest requiring emergency transportation to the hospital.

Use a symbol, color, or label to identify each possible solution. Place the solutions in the diagram according to these assessments.

Assess the effort and impact for each solution.

Construct an empty diagram with the effort required to implement the solution on the horizontal axis and the impact of the solution on the vertical axis, and divide it into four quadrants.

Retrieve suggested solutions from previous discussions.

Impact Effort Matrix ProcedureĬonstruct an impact effort matrix through the following steps: It provides answers to the question of which solutions seem easiest to achieve with the most effects. Like force field analysis, a more basic RCA tool, the impact effort matrix was designed specifically for the purpose of deciding which of many suggested solutions to implement. The impact effort matrix is an advanced tool for root cause analysis (RCA) that can help you take action once the root cause has been identified. Quality Glossary Definition: Impact effort matrixĪlso called: effort matrix, impact matrix, 2x2 matrix