Accreditation Audit Task 2
Sentinel Event
Western Governors University
Accreditation Audit Task 2
Sentinel Event
Nightingale is a well establish Community Hospital, which has been servicing the community by providing excellent, and compassionate healthcare provides for their patients’ needs. There values statement pledge to themselves and the community, is a commitment to four core values the first being Safety with the quote “We put our patients first”.
A1 Sentinel Event As defined by the Joint Commission (2014) a sentinel event is an unexpected occurrence involving death, or serious physical, psychological injury, or the risk thereof. With this said Nightingale community Hospital recently experienced a sentinel event
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The pre-op nurse did not pass the information on when giving report to the OR nurse. The OR nurse is responsible for giving addition hand off information both about the patient along the information from the procedure she all so communicates with the surgeon during the procedure. It was during this interview that some insight about a breakdown in communication between departments became apparent.
The recovery nurse, who attended to the care of the patient during her post- anesthesia, this nurse had attempted to contact the mother by overhead paging her to the waiting area, the recovery nurse was unaware that the mother was not in the facility and needed to call her. The recovery nurse had a negative approach, on the hand off process that this facility has in place
After the recovery process was completed, the patient was placed in the care of the discharge nurse. She was given a report and was aware that the mother had not showed up to collect her child and several overhead pagers had been performed. While the interview was taking place the nurse stated that she was unsure how to proceed, with the mother not being located, the nurse stated that she was relieved when she was informed that the patient father was there, the discharge nurse stated that the
A nurse attending stated “during the morning’s second surgery, he actually dozed off. The nurse took him aside and recommended that he take a break, but he refused and returned to the operation.” The nurse here was in fault in more ways than one. This nurse should never allowed the doctor return back to operate on the patient, he should have been removed from the operating room immediately. The nurse should have
Nightingale Community Hospital provides leadership in quality health services. We also provide compassionate and cost-effective service in the lines of treatment and prevention.
Nightingale’s theory has made a difference in healthcare over the years and still has an impact on healthcare today.
There was no hand off of the cell phone number the mother provided to the pre-op nurse. As there is no documented area on any of the forms for this information, the process relies on verbal handoff and memory of the nurse. There was no alternate phone number available for the nurse to contact the mother or other designee.
In the 25th week of her pregnancy, the mother was advised by the nurse to remain on bed rest to avoid further complications and potentially hurting her unborn baby. The mother continued to work from the hospital placing additional stress on the baby despite the nurse’s appeal that such stress can cause the baby harm. Attempts to stop premature delivery were made but failed, the mother asked the medical team not to take any extraordinary measure to save the baby. The premature baby lived but the mother showed little interest in his health and wellness. The nurse tried to the best of her ability to spark
Sentinel event refers to the occurrence of serious physical illness or death or psychological injury or even those incidences whose recurrence involves risks with adverse and serious outcomes. It may result into deaths that are not anticipated or permanent loss of a major function that is not associated with patient’s natural cause of illness or condition (Lewis et al, 2014). The causative factors of Mr. B’s demise, according to the scenario described are that Mr. B was not put on oxygen or an EKG monitor
Specifically, the pre-op nurse who acquired the parental contact information, or upon being informed that the mother would be leaving the facility did not document it in the patient chart or pass it along to the O.R. nurse.
* Personnel Issues: One of the key barriers to effective interaction for the pre-op nurses is that they are not getting any information from the registrar or the surgeon related to the patients unique circumstances. There is not a communication process in place for the pre-op nurse to actively communicate with the surgeon or his office regarding a patient’s care during their day of surgery. An additional factor in this situation was the pre-op nurse documented the mother’s contact information in her notepad, but not on the
Communication, this is the key focus area that is evaluated in this summary. Communication is a key focus area of the joint commission audit and is also a key area in which Nightingale Community can make enhancements. Communications must be a two way free flow of information. The information exchanges occur between providers, staff, and patients or clients. This was an area that needed improvement was noted in the previous accreditation audit. Some noted prior issues from 2 years ago included patient and family education and information not being properly disseminated to the nursing staff. These are areas where we have targeted and currently meet. Some areas that we continue to work on are as follows.
Nightingale Community Hospital is a 180-bed acute care hospital that is a not-for profit entity. The hospital is community based and provides leadership in quality health services in which they provide. Their vision is to be the hospital that people choose, the place employees, physicians and volunteers want to work and a hospital of choice for the community. They are committed to providing a healing environment to their patients with a compassionate commitment to healthcare excellence.
5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.
Sentinel events are a subset of medical adverse events. Events that require immediate attention are called Sentinel Events. Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Sentinel Event identified by Joint Commission also include infant abduction or discharge to the wrong family.
Evaluation is the third stage of Gibbs model of reflection and requires me to state what was good and bad about the event. While reflecting back on the incident I felt that there was one thing which I could have dealt with differently and also some aspects which demonstrated good practice. On the first hand, this incident made me realised that I was part of the team and that I was also involved in positioning and preparing the patient prior to surgery, therefore I had a responsibility to find out from the patient if he had any concerns. On the other hand, I should have communicated to the patient, explaining what I was about to do maybe he would have had the opportunity to raise his problem with the shoulder before lifting his arm. The Health Professions Council (HPC 2008) clearly states that it is the responsibility of an operating department practitioner to ensure that effective communication occurs when delivering patient care. In addition, Psychologist Helmreich, R. (2000) said, `better communication’ is being the most useful way of reducing errors.
I would not agree with you more that Nightingale is the foundation of the nursing society. In my opinion, anyone who works for the health care industry should be like Nightingale; we should all going into this profession as to providing the best care and thinking about the patient’s safety instead of driven by the pay. Because of Nightingale, the nursing profession become the one of the highly respect career instead of the low class career that everyone looked down on back in the 1800. If she did not started the school of nursing and set the standards and responsibilities for future nurses to follow, the nurses today will probably feel lost in which direction to take when comes to decision making and providing care. If Nightingale did not illustrate
Nightingale Community Hospital provides professional care that ensures total security and satisfaction to those who wish to benefit from our care.