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
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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
The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009).
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
Disclosure of sentinel and adverse events has been an ongoing issue in healthcare. According to King, the Institute of Medicine reported that 44,000 to 98,000 people die every year from medical errors (King, 2009), According to the National Center for Ethics in Health Care, a sentinel event is a unanticipated death or outcome which is not related to the patient's underlying illness (National Center for Ethics in Healthcare, 2003). Josie's Story by Sorrel King is based on a true story which depicts a heartbreaking yet inspiring story of a young child whose live was taken due to a sentinel event. According to King, Josie died unexpectedly due to a sentinel event. A sentinel event is an event in which there has been an unanticipated outcome resulting in death or further complications. The healthcare team's duty was to investigate Josie's case, and come up with a resolution to avoid it from happening in the future (King, 2009).
Paul Mountjoy, a reporter of the Washington Times, asks whether medical errors are ranking third in causing deaths in US. In the article, he notes that medical error complications are an emerging major public health issue as he reports that nearly 400,000 American patients die annually due to complications resulting from medical errors. The trend seems to be growing because nearly 10 years ago the figure was nearly 250,000 cases. This is according to a report by Dr. Starfield. Without much guess, this confirms that actually medical errors rank third in killing American citizens. Cancer and heart complications of course take the lead.
That is the rising number of negligent acts committed by medical professionals. Failure to follow standard of practice is the leading root cause of the troubles involving malpractice. Failure to assess and monitor the patient, failure to communicate, medication errors, negligent delegation or supervision and failure to obtain informed consent from patients are the top failures leading to malpractice. The American Nurses Association provides scopes and standards that if followed could prevent many of the negligent acts. Duty, Breach of Duty, Foreseeability, Causation, Injury, Damages must be proven for a nurse to be held
In order for hospitals to be reimbursed from government based insure companies certain standards must be met. When standards are not met, any subsequent cost in relationship to preventable errors will not be remunerated (Youngberg, 2011). These preventable errors are termed never events. Never events are considered error that can be prevented if certain checklist and guidelines are in place are followed such as medication errors, falls with injury, wrong surgical site, and pressure ulcers (Agency for Healthcare Research and Quality, 2012). There are currently ten mandated never events (Youngberg, 2011). In order to avoid these preventable human errors, risk manager help implement policies and procedure. This process based on risk analysis and outcomes which helps to improv...
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
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.
To start off, the article’s introduction states that one of the leading causes of medical error and patient harm is due to ineffective communication of health care professionals. Specifically the article states, “A review of reports from the Joint Commission reveals that communication failures were implicated at the root of over 70% of sentinel events.”(Dingley, 2008). So basically, 70% of circumstances
Licensed practical nurses (LPN 's) fill an important role in modern health care practices. Their primary job duty is to provide routine care, observe patients’ health, assist doctors and registered nurses, and communicate instructions to patients regarding medication, home-based care, and preventative lifestyle changes (Hill). A Licensed Practical Nurse has various of roles that they have to manage on a day to day basis, such as being an advocate for their patients, an educator, being a counselor, a consultant, researcher, collaborator, and even a manager depending on what kind of work exactly that you do and where. It is the nursing process and critical thinking that separate the LPN from the unlicensed assistive personnel. Judgments are based
When I first decided to come to college for nursing after staying in university for three years, I had an argument with my parents because they were not happy with my decision. My parents just wanted me to finish rest of my degree and they thought that it did not make sense to go to college for diploma, and not complete the university degree. However, I just wanted to complete my nursing diploma in the same amount of time that I can finish my degree in the university because I always wanted to be a nurse.
This paper explores the concept of culture, its definitions, and its application to nursing and health care. Culture is a group's customs, habits, morals, and shared beliefs. The understanding of culture, not only as a concept, but how it relates to health care is imperative for providers. The lack of cultural awareness, or competency, leads to miscommunication, inadequacy of care, and health disparities among individuals and groups. Jehovah’s Witness’ are one group of individuals with defined morals and beliefs that can be at odds with routine health care: they do not accept most blood products. Understanding how culture can impact a patient, their needs, and beliefs can improve patient outcomes and improve satisfaction rates.
A leader is described as a person who guides others and has authority and influence over others. They work to influence others into meeting certain goals. There is no right or wrong definition of a leader and there is no recipe that ensures effective leadership. Successful leaders have a good balance of vision, influence, and power. Leaders gain their authority from their ability to influence others to get the work done; because of this, anyone has the potential to be a leader. (Finkelman. 2012, p15)
However, the reasons regarding these errors can be improved the truth is that errors do occur, and that is tragic although solutions can be made. Some factors contributing to these errors include polypharmacy, constant interruptions while medication preparation or administration is being conducted, along with under reporting incident slips which lead to future errors of the same nature since correction did not occur (Anderson, 2011). The nurse has a responsibility to progress improvements in risks that could impact patient safety by reporting any and all ineffective protocol that has been applied. However, this may not be completely followed through by the nurse due to fear of disciplinary action, guilt, liability of lawsuits, along with having lack of recognizing a medication error or an anonymous error-reporting system (Anderson, 2011). As many more safety and quality problems have surfaced over time some improvements have been created to secure patient safety, yet these improvements are also constant analysis to fine tune any future breaks in the
Medical and medication errors and adverse events are well known issues in the health care industry, regardless of country. Errors are either the correct implementation of the wrong procedure or the wrong implementation of the correct procedure (IOM, 1999 pp23-25). Adverse events are considered unintended injuries and/or harm that are caused to the patient but not necessarily due to human error. This proposal will present a technical solution, using case based reasoning, to help prevent the occurrence of errors, thus reduce adverse events, and to make suggestions to the line staff as to what to do when such an event or error happens.