Sentinel

hospital administration will take the necessary actions to ensure that a child abduction sentinel event never occurs again. One resource that will be used to support the changes to the risk management program will be mandatory monthly training luncheons for the nursing teams. The Chief Nursing Officer will conduct the training luncheon program by using slides and computer presentations covering potential sentinel events and the steps required to prevent the occurrence, nursing documentation…

The root cause of the event was the hospital not providing a professional translator to translate for the patient who was complaining about severe abdominal pain. 2) Identify the type of event if applicable (sentinel, adverse or never) a. What happened to the patient could be a sentinel event, because with the hospital using nonprofessional translators, it could lead to the risk of the patient receiving the wrong treatment he would need. 3) Identify the standard of care that was breached (if…

Risk management programs are essential to any hospital. While it is known that humans will make mistakes, it is imperative that risk managers do what is necessary to assist the health care workers in providing quality care for the patients. A good risk manager will accomplish this task while minimizing risks to the patients, health care staff, and the organization. Risk Manager’s Role The purpose of a risk management program is to reduce the likelihood of errors that are costly to an…

A King’s Duty A leader must do what is right for his countrymen and be loyal to his country. In Sophocles’ Antigone, Creon the King of Thebes makes the proclamation prohibiting to bury Polyneices because he betrayed Thebes and his family,and if someone did bury him they will be killed. Antigone, a sister of Polynices, defies his law and buries her brother knowing the consequences of her actions; Creon being loyal to his country and his law sends Antigone to her death. Creon promoted social…

Capitan is another famous granite rock formation that rises over 3,000 feet above the valley floor, and is a vertical rock formation that is very difficult to climb. Other granite rock formations include Cathedral Rock and Spires, Three Brothers, Sentinel Rock, and Glacier…

to be motivation for change. The sentinel event involving Mr. B. is an excellent example. An incident like this can instill motivation for the staff and enable “unfreezing” of the system. This “unfreezing” is the point in the change process where everything is broken down into smaller pieces or individual parts. This…

Focus Sheet 2: Work Place Safety/Patient Safety Define the terms, Safety, error, Adverse event, near miss and event according to the Institute of Medicine While examining safety and precautionary measures on the job it is important to have clear universal definitions to refer to when discussing safety. The Institute of Medicine provided definitions to clarify certain safety terms, which were published in 1998, and are known as a common language regarding safety. The key safety terms issued by…

regulatory organizations that accredits and certifies more than 20,500 health care organizations in the United States. The Joint Commission, an independent, not-for-profit organization, published that by mid-2015, 474 Sentinel events have been reported. In 2014, 764 events were reported. Sentinel events are occurrences that indicate unsafe processes, for example, wrong site surgeries, delays in treatment and retention of foreign body (object left in patient’s body after surgery). In order to…

requires an intervention in order to sustain the individuals life (Joint Commission, 2014, p. 1). Events of this severity are referred to as “sentinel events” since they signal the necessity for instant investigation and response (Joint Commission, 2014, p. 1). Among the most often occurring sentinel events are suicide and falls (Ten Most Common Sentinel Events, 2004, p. 35). System Factors Influence on Organizational Performance System factors are a major influence on performance of an…

Situation briefing, currently in use in healthcare facilities, exists as an adaptation from the United States Navy, the situation, background-assessment-recommendation (SBAR). The SBAR is instrumental in diminishing sentinel events by promoting excellent communication especially in transference of care from one practioner to another (Fassett 2011). While root cause analysis is essential in uncovering the critical facts and reasons for an occurrence of an adverse reaction…