Essay On Nursing Event

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Incident Report Sentinel Events and Root Cause Analysis As a health-care professional, it is understood that the health and well being of a patient is top priority. The dedication to provide care and protection to each patient is ingrained into the very basics of nursing education. However, despite this commitment, medical errors that adversely affect the lives of patients are made everyday worldwide. These types of events are referred to as Sentinel Events. When such an event occurs, there is a need for an immediate investigation and response. This investigation and response is addressed using a methodology called Root Cause Analysis (RCA). With the understanding that mistakes do happen, it is the responsibility of the healthcare system…show more content…
Other qualifying events include: suicide of a patient within 72 hours after release from a medical facility, discharge of an infant to the wrong family, rape or assault of any patient, staff member, or visitor while in the hospital facility, surgery on the wrong patient or wrong body part, and unintended retention of a foreign object in a patient after an invasive procedure or unexpected death during surgery or within 24 hours after anesthesia begins (on an otherwise healthy patient) (CAMH, 2017). The Joint Commission provides a full list of possible sentinel events on their…show more content…
By reviewing the trends in sentinel events and taking corrective actions, healthcare agencies can provide effective and sustained system improvement. The ultimate goal is to reduce risk and prevent patient harm (CAMH, 2016). The goals for the policy is to have a positive impact in patient care, to understand the factors that contributed to the event, to increase general knowledge of patient safety, and to maintain confidence of the public, clinicians, and hospitals (CAMH, 2016). Hospitals are not required to report a sentinel event to the Joint Commission but it is strongly encouraged. They are however required to review all sentinel events and provide a thorough and credible comprehensive systematic analysis and action plan within 45 business days of the event or of becoming aware of the event (CAMH, 2016). Failure to do so could result in loss of accreditation and possible fines. Hospital administrators work diligently to retain accreditation status by reporting and responding in a timely manner to all JCO requests. A comprehensive system analysis will include: all relevant patient documentation, statements and input from the patient (if possible), patient’s family members, and individuals closely involved in the event. The hospital CEO, or senior leader, will consult with an internal Incident Response

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