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Explain system changes that were made as a result of this event as well as the outcomes of those changes.

.Explain system changes that were made as a result of this event as well as the outcomes of those changes. 

System-Wide Safety Failures every system is perfectly designed to achieve the results it gets. —Dr. Paul Batalden In the years following the publications of To Err Is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century, increased attention was given to mitigating the circumstances in which patient safety is compromised. Increasingly, adverse events that occur within healthcare organizations are recognized, not as the failure of any individual (health provider or patient) but as system-wide failures. High-profile sentinel events, such as Libby Zion, Josey King, and the Quaid twins, to name a few, have attracted public attention and spotlighted the tangled or missing systemic threads that can lead to serious outcomes. Likewise, in this environment, adverse events that might cause little or no harm are gaining increased attention. This shift in perspective is having a profound and ongoing impact on how healthcare is delivered, regulated, and reimbursed. Bring to mind an adverse event that has been publicized or one with which you are familiar, one for which there was a resulting systems change. With this event in mind, respond the following: Analyze the adverse safety event that became an impetus for systems changes related to patient safety as follows: Describe the event and its effects on key persons involved. (2–3 paragraphs) Explain the systemic failure that allowed the event to occur. (2–3 paragraphs) Explain system changes that were made as a result of this event as well as the outcomes of those changes. (2–3 paragraphs)