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Action Plan

At least one action is recommended for each Causal statement. Each action should include:

  • Who is responsible
  • Expected completion date
  • Method for measuring effectiveness
  • Projected effectiveness assessment date

After the Action Plan is developed it should be presented to the organization leadership to obtain concurrence and authorization for implementation. If it is decided that an action will not be implemented, the reason should be documented.

Causal Statement


Responsible Personnel

Outcome Measure

Measure Date


Concur (Y/N)

The absence of a system to ensure patient's nutritional needs are being addressed results in some patients missing meals for as long as 24 hours when diet orders have not been processed, or not clarified when an order is absent, increasing the likelihood of a hypoglycemic event. Nursing Unit Clerk will print the patient diet report daily and give it to the charge RN to review and clarify if diet orders are absent. J. Smith New process is implemented 5/15/09 Y