2.3 THE sentinel event the sentinel event can be defined as an unexplained incident or event
It causes death or serious physical or psychological consequences, or risk are you.
2.4 Classification of sentinel events
There are many ways to classify the sentinel event, one of the most useful regarding the definition of ethics, criminal, civil and administrative liability, it is one that divides it into preventable and non-preventable sentinel event. The sentinel event is not preventable complication that can not be prevented given the current state of knowledge; the sentinel event is preventable bad outcome of care that can be prevented with the state of knowledge.
2.5 CAUSES OF THE APPEARANCE OF SENTINEL EVENTS
To argue the first goal set, it
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In intensive care units it recorded the impact I could get to have a high incidence of sentinel events. The incidence may be underestimated because the data and results obtained are not the totality of the events by the known missing or insufficient information. Knowledge of the possibility of the occurrence of sentinel events and consequences that occur after the occurrence of this during the care provided by nurses in the ICU, constitutes an essential tool for providing your care with higher quality and more certainty.
2.7 SENTINEL EVENTS AND NURSING
All this is framed within an overall clinical context, it is mean that approximations have previously reflected approach from the point of view of specific nursing approach that it was mold thereafter. For nursing recently she created a taxonomy of errors classified as: inattention clinical conditions and reaction to in place, lost the role of representing the best interests of the patient, clinical judgment inappropriate, error treatment, lack of intervention on the clinical evolution of the patient, lack of preventive care, mistake in the execution in the prescription and treatment errors in the documentation. Each activity included in the process of nursing care is intrinsically thus a risk of error in the other variables which also involved as such practices,
In the case study identify the incident and explain the problem that might trigger a root cause analysis. In this case study, a patient admitted to the intensive care unit (ICU) with septic shock requiring vasopressors that suffered an MI in the course of his treatment due to vasopressin overdose as the incident. The problem that triggered a root cause analysis was likely related to a log increase in the dose of vasopressin because of a prescribing error, pharmacy issues also figured prominently in this error, the computerized physician order entry (CPOE) system that did not eliminate medication errors and domino effect to the nurse that started the medication that eventually caused the patient to have an MI. The patient in this case was receiving the medication vasopressin, at a dose of 0.4 units/min, a dosage used for gastrointestinal hemorrhage and variceal bleeding rather than the correct dose of 0.04 units/min for treating shock. The vasopressin order was incorrectly written by a resident physician after he received a verbal order from his supervising critical care fellow (Flanders, S. & Saint, S., 2005).
The article quotes this as the “worst type of preanalytical error”. The reason behind this is the result of this error means that a patient is treated for a disease or illness that they are not suffering from. This could be by medication or treatments even as extreme as chemotherapy. Problems that then grow from this is the effects of the treatment can be life threatening as they are managing a condition that isn’t there. An example of this is if a patient is incorrectly prescribed warfarin, an anticoagulant to treat blood clotting but has no issues with blood clotting the blood will thin and increase blood pressure leading to serious health defects.
Nurses have a considerable amount of responsibility in any facility. They are responsible for administering medicines and treatments to there patient’s. While caring for there patients, nurses will make observations on patient’s health and then record there findings. As well as consulting with doctors and other healthcare professionals to plan proper individual patient care. They teach their patients how to manage their illnesses and explain to both the patient and the patients family how to continue treatment when returning home (Bureau of Labor Statistics, 2014-15). They also record p...
Rush, S., Fergy, S., Wells, D., 1996. Nursing Process. [pdf] Available at: [Accessed 05 December 2013].
After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner.
As a nurse we are responsible for the safety and overall health promotion of our patients. Competency in the nursing field is what ensures patient safety and decreased hospital acquired injury. Continued competence ensures that the nurse is able to perform efficiently and safely in a constantly changing environment. Nurses must continuously evaluate their level of skill and find where improvement needs to be made in order to keep up to date with the expected skill level set by their
When evaluating medical malpractice, this can be performed by any healthcare professional. It is easy to classify this to be misdiagnosis, delayed diagnosis, delayed treatment, even not taking the time to evaluate a patient properly. When practicing medicine it is important that all measures be taken when a patient is showing signs of infection or having any adverse reaction to medication. In the case study below this is a prime example of the importance of checking patient progression.
As conversed throughout this case, nurses play a vital role in the health care setting. They are those who are there from the beginning to the end to improve quality of life for each individual. Nurses peruse quality of life by performing specific appropriate for the client; these include assessment tools, setting goals and interventions to provide the best possible outcome. Thus, the importance of this case is to demonstrate the nursing skills regarding to an individual and their health situation. Allowing the nurse to enhance the quality of care and ensuring safety at all times is achieved for the individual and overall performance.
The Joint Commission (TJC) defines a sentinel event as an unforeseen incident that results in critical injury or death of a patient (Cherry & Jacob, 2017). After a sentinel event has occurred, TJC mandates the healthcare facility perform a root cause analysis (RCA) so they fully understand the why the event happened and can implement an action plan to prevent them from recurring (Cherry & Jacob, 2017). TJC will review the RCA and subsequent interventions taken by the facility to determine if they complied with national quality standards. In this reflection I will review some of most common root causes of sentinel events, pinpoint the root cause that I believe poses the greatest risk to patient
Spark Ralph, S. & Taylor, C. M. (2011). Nursing diagnosis reference manual (8th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
A 2013 alert issued by the Joint Commission brought alarm fatigue to the forefront of healthcare safety. The investigation prompting the alert cited alarm fatigue as the most frequent contributing factor in 98 alarm-related sentinel events that were reported between January 2009 and June 2012. Of those 98 events, 80 resulted in patient death and 13 resulted in permanent loss of function (Joint Commission,
Nursing is a profession that I have always been fascinated with. Nursing is defined as "health promotion, health maintenance, health restoration and providing care to the sick and dying" (Kozier and Erb). There are five values essential to nursing, which include altruism, autonomy, human dignity, integrity and social justice (AACN). Nursing is a profession in which the nurse uses caring as a central concept. Some other characteristics of the nursing profession include art, science, advocacy, and offering holistic care. Nurses use critical thinking in order to problem solve because every patient is unique. The nursing process when assessing a patient includes, data collection, analysis, planning, implementing, and evaluation. Nurses need to be able to deal with change in stressful, fast paced, hectic environments. The treatments and technology is constantly changing therefore nurses need to be able to make quick and important decisions.
It is necessary that as an advanced practice nurse that we are educated on disorders that exist in today’s society. Our knowledge on numerous disorders, will eventually influence our practice in a positive fashion. Being competent in properly diagnosing individuals and providing the correct treatment plan have a tendency to heighten the individual’s outcome. In this assignment three scenarios will be reviewed. After reviewing each scenario, a diagnosis will be constructed and the pathophysiology description of each disorder will be stated.
Flanagan (1954) defined critical incident as extreme behavior either outstanding effective or ineffective with respect to attaining the general aim of the activity. A critical incident also defined as an unintended event that occurs does not from the patient’s illness but when health services are provided to an individual and resulting serious and undesired events such as death, disability, injury or harm, and lead to prolong hospital stay. “Public Hospitals Act (PHA,2010)”.
She further identified seven concepts that are essential to current nursing practice, she stated that,” Based on the acronym FLOWERSTM, they include fundamentals of care, leadership at the bedside, ownership of outcomes, wisdom, ethics, relational competence, and skilled caring.” (Sprayberry, 2014, p.123). Nursing professionals play several key roles, which directly affects client outcomes, such as, critically thinking while being the patient-caregiver, advocate and educator along with coordinating and collaborating with the various members of the multidisciplinary health care delivery team. Nurses always prioritize excellent patient safety and care every day and collect information and recognize the practices that need improvement. For example, the process of identification and documentation of nursing-sensitive outcomes that are a direct result of nursing assessments and interventions. Nursing professionals take leadership roles concerning promoting safety and quality through collecting evidence, analyzing and interpreting the data necessary to improve practice. Armed with the edge of working closely with clients, nursing professionals can identify opportunities of cost-effectiveness without compromising on QI. Through being patient advocates, nurses ensure, that health care clients receive good quality and