Wgu Organizational Trends Essay

378). Hospitals have an array of medical devices at the bedside that have alarms, which have grown significantly within recent years. Nurses may be exposed to over 350 physiologic alarm monitors per day, resulting in sensory overload thus leading to desensitization. When the alarm sounds it should be corrected immediately, even though it may be a false alarm or no issues with the patient. The Joint Commission has identified alarm fatigue as a 2014 National Patient Safety Goal, requiring hospitals “to establish improvement of alarm system safety as an organization priority” (as cited in Horkan, 2014, p. 83). Alarms are deliberately designed for high sensitivity so that nurses do not miss a true event. Firing alarms are usually muted, disabled or ignored by nurses altogether because alarms are viewed as a nuisance. Alarm hazards have generated national attention, in one highly publicized case an alarm sounded for 75 minutes before a nurse responded to a patient’s heart monitor that needed a battery replaced. When the nurse finally went to change the battery the patient was found unresponsive and could not be resuscitated because he had gone into cardiac arrest (Sendelbach & Funk, 2013). The patient’s heart monitor battery eventually died and did not issue the critical alarm alert. In another event, a patient fell getting out of bed and bleed to death because the nurse

An organizational analysis is an important tool to become familiar with how medical businesses and organizations are able to meet standards of care, provide services for the community and provide employment to health care providers. There are many different aspects to evaluate in an organizational analysis. This paper will describe these many aspects and apply the categories to the University Medical Center (UMC) as the organization being analyzed.

One key responsibility of working as a manager is to recognize the best way to organize and run an organization. A manager who can work with and put into motion the structure and plans of a company is very important to the life of the organization. Chief Executive Officer of Chick-fil-A Dan T. Cathy is an example of such a manager and business owner. Chick-fil-A began its journey in 1960 in Hapeville, Ga. Since then the second

To organize and prioritize the current and future projects in the pipeline in a way that fits into the PMB budget of $5B, and ensures projects that increase sales, growth, and stockholder value are of top priority, whereas projects that are not beneficial are either put on hold or discarded.

Root cause analysis process will utilize a systematic step-by-step approach to help identify all causative factors leading to this sentinel event. The main purpose of the Root Cause Analysis is to understand how the event happened, why did it happen, and what can be done to prevent an event from happening again. The first step, collect all necessary data associated with this event such as: current policy and procedures, incident report, Mr. B’s health history, environmental flowcharts, dispensed medications, equipment and staffing factors relevant to the event. The process of identifying causative factors can begin once all the data is collected. The goal, of a Root Cause Analysis, is to identify interventions to prevent an event from reoccurring.

We then look at the errors of hazards that occurred in the Mr. B scenario.  Though we can say understaffing may have contributed to Mr. B’s demise, we cannot blame understaffing. This scenario is regrettably connected to inattentive nursing practice. It is clear that respiratory therapist was in the building and

A policy for conscious sedation was in place and not followed by staff. As all staff had been trained in the procedure, completed the appropriate modules, and

A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause, or causes, that led up to the event. Although personnel are involved in these events, the primary purpose of the RCA is to identify the cause, not to assign blame (Agency for Healthcare Research and Quality, 2014). It is through identifying a cause, or causes, of an adverse event that we can improve on patient care processes and thereby patient safety. The RCA is designed as a specific protocol that starts with data collection looking at the sequence of events that led to the

After careful analysis of what had happened and what should have happened takes place, the RCA team should ideally focus on why the adverse events happened. In this step, the goal is pinpoint the direct causes and contributory factors (Ogrinc & Huber, 2013). By doing this, the root cause of an event can be identified. One suggestion made by the Institute of Healthcare Improvement in the root cause analysis process is to ask “Why?” five times (Ogrinc & Huber, 2013).

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.

The purpose of this paper is to analyze the unfortunate sentinel event of Mr. B, a sixty-seven-year-old patient presenting with severe left leg pain at the emergency room. A root cause analysis is necessary to investigate the causative factors that led to the sentinel event. The errors or hazards in care in the Mr. B scenario will be identified. Change theory will be utilized to develop an appropriate improvement plan to decrease the likelihood of a reoccurrence of the outcome of the Mr. B scenario. A Failure Modes and Effects Analysis (FMEA) will be used to project the likelihood that the suggested improvement plan would not fail. Lastly, key roles nurses would play in improving the quality of care

“A central tenet of Root Cause Analysis (RCA) is to identify underlying problems that increase

A significant quality improvement issue that has been implemented triggering one to reevaluate how their tasks are performed and care is given is a sentinel event. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) describes numerous patient safety measures with a sentinel event being one. The purpose of a sentinel event is to recognize an event, reduce further risk, prevent future injury or harm, learn from the experience, and prevent it from happening again. A sentinel even is defined as an unforeseen incidence that may include serious physical, psychological injury or death and can include loss of limb or function (www.jointcommision.org). Implementing sentinel events by educating staff on what a sentinel event

Topshop was founded in 1964 in Sheffield within the ladies fashion store chain Peter Robinson Ltd. The first official stand alone store was opened in 1974, followed by Topman being introduced in 1978 exclusively for male customers. Topshop has over 300 stores in the UK and over 100 stores internationally and has a flagship store in both London andn New York. It is part of the Arcadia Group which also owns Dorothy Perkins, Burton and Miss Selfridge.

A sentinel alarm event occurred at several hospitals within the AW Network, which prompted the Pennsylvania Department of Health to conduct a Center for Medicare Services level investigation. This type of investigation requires an action plan with a measure of correction. Parallel with the alarm events, the Joint Commission had created the National Patient Safety Goal 06.01.01, also known as goal six, to reduce harm associated with clinical alarms (The Joint Commission, 2014). The potential patient risks for an adverse event from alarm mismanagement are experienced around the world, and while the particulars of each event varies; research suggests that by reducing nuisance alarms, the chance for an adverse event diminishes (Gorges,