Refer to pp. 57–109 of Book I, “The Nebraska Hepatitis C Outbreak,” of A Never Event. In A Never Event, Nurses Mayberry and Winke made several recommendations to Dr. Javed stemming from the Missouri Valley Cancer Consortium audit, but Dr. Javed was reluctant to act on these recommendations.
As a leader, what actions would you take to address the deficiencies identified by the Missouri Valley Cancer Consortium audit and the Nebraska Health and Human Services investigation? How would you prioritize them?
What resources might be accessed to assist you as you develop your plan?
What systems would you recommend be put in place to prevent this situatiluvon from occurring in the future?
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