The risk manager will adhere to the Joint commission requirements for reporting sentinel events for accredited hospitals. “Accredited hospital are to identify and respond to any sentinel event in a timely and through manner.”( Radtke, K., & Milton, C. (2003). The Requirements include a credible root analysis and the development of an action plan that reduces risk and improves patient safety measures. The process of the root analysis should find risk in areas like performance but should focuses primarily on systems and processes. The focus should not be limited to the level of individual performance. While doing the analysis, it should progress from special causes then to clinical processes and will conclude in common causes. The analysis
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All documentation of treatment, services provided, findings of assessment, conclusion from medical history and the physical examination will be included in the analysis. Also included is what the diagnosis of the condition was and treatment plan and goal. The risk manager must gather all records and documents pertaining to procedures and care methods. All medications ordered and administered to mother and infant should be reviewed. After evaluation of records there will be formal interviews of nursing staff and pharmaceutical technician and acting physician. Hospitals policies will be reviewed to seek improvements in order to stop reoccurrence of sentinel events.
Risk Management must request complete reports from the advanced level nursery nurse who administrated the medication and the nurse on duty who was caring for the infant and from the pharmacy tech that filled order of the medication request. A complete analysis of the events that led up to the demise of the infant in question is completed. The analysis will conclude what human factors are in need of direct improvements in the implementation of safety for patients.
After all analysis of root cause and imploring the Swiss cheese model along with latent vs active failures and in measuring the facts of