...AFT Task 2 A1. Sentinel Event The Joint Commission’s definition of a sentinel event is “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 risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (http://www.jointcommission.org). The Joint Commission list specific events that are considered reviewable. One of those events is the abduction of a patient On Thursday, September 24th, at approximately 12:30 p. m., a mother arrived to pick up her daughter from the hospital’s outpatient surgery department. The mother left 2 ½ hours earlier to run an errand. When the mother arrived, she was told that the child had been discharged. The child’s mother and father are divorced, and the mother has sole custody of the child. A “code pink” child abduction was called, and local law enforcement notified. The child was found unharmed thirty minutes later at the home of the child’s father. The mother brought the child to the hospital for outpatient surgery that was to take approximately 45 minutes with a period of recovery of one hour. The mother requested that the nurse call her on her phone should the child get out of surgery early, and she left her cell phone number with the nurse. After the mother left, the father came to visit the child. The nurse stated...
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...A1: Sentinel Event Describe the Sentinel Event On September 14 at 12:30pm, pediatric patient Tina was involved in what was thought to be a child abduction. After arriving at the hospital that morning, Tina’s mother checked Tina in with the registrar. The registrar collected Tina’s demographics and insurance information and entered it into the medical records. She made copies of ID’s and insurance cards and had Tina’s mother sign all necessary paperwork for Tina’s surgery. The registrar did not ask for any information regarding the custody of Tina because it was not a part of her job duties. Once admitted, the Pre-op nurse greeted Tina and her mother. The Pre-op nurse had Tina’s mother sign all consent forms for the surgery. She then helped Tina get gowned up and began the pre-op assessment on Tina, started her IV and administered her pre-op medications. According to the Pre-op nurse, Tina’s mother did inform her that she’d be doing something with her son during Tina’s surgery. Tina’s mother gave the Pre-op nurse her name and number, which the Pre-op nurse wrote down in her notepad, so she could be called when the surgery was done. The OR Nurse had very strong feelings on the lack of communication between departments. She said that she has witnessed many issues and seen many problems arise due to a lack of communication and understanding across departments. She strongly believes that working more closely with security would eliminate some of this issues in the future. Following...
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...AFT2 Task 2 A1. Summary of Sentinel Event A recent sentinel event occurred at Nightingale Community Hospital involving the possible abduction of a 3 year old patient. According to the Joint Commission, a sentinel event is one that is unexpected and results in death or serious injury (2015). According to the documents and interview provided, a child Tina was admitted into the hospital on September 14th by registration. Insurance and demographic information was collected by registration. The patient then went to pre op with his mother for outpatient surgery. The pre op nurse then prepped the patient for surgery by having the mother sign the consent form, changing into appropriate surgical attire, and starting the I.V. The pre op nurse told the mother the procedure would take about 45 min and then the patient would be in recovery for at least an hour. The mother had to leave to take care of an errand with her other children and had left her cell phone number with the pre op nurse. She instructed the pre op nurse to call her if her daughter was done sooner. The pre op nurse put down her number in her notebook. After the completion of the surgery, the patient was taken to the Post Anesthesia Care Unit (PACU). Upon arrival in PACU, the mother had not returned. The patient was becoming uneasy that her mother was not back, the PACU nurse had the mother paged on intercom but it was determine that she had not returned. The patient was then transferred to the discharge nurse who was...
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...A1. Sentinel Event On the evening of September 14, 2011 a sentinel event occurred at Nightingale Hospital. According to Joint Commission, a sentinel event is characterized as an unexpected occurrence involving death or serious injury mother proceeded physical), or the risk thereof (http:www.jointcommission.org). A three year old child was accompanied by her mother for an outpatient procedure scheduled for September 1, 20111. The mother proceeded to register the child for the procedure and was provided details regarding anticipated length of surgical time and physical assessment. The pre-operative nurse was informed by the mother of the child that she needed to run an errand but left contact info(i.e. cellphone number) with the child’s nurse in the event the surgical procedure was to end sooner than expected. Unfortunately, the pre-operative nurse did not chart this pertinent information in the patients chart, it was documented on a sticky note attached to the chart. Post-surgery, the child was taken to the recovery area with care assumed by a recovery team without sight of mother. The father of the child presented to the recovery room and began hugging the child and was able to verify child’s name, date of birth, and was listed on face sheet in chart as father of the child with proper identification. Discharge instructions were provided to the father and the child was released in the fathers’ care. Approximately two and a half hours later, the mother arrived to the unit to...
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...Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis Accreditation Audit (AFT2) Task 2 Executive Summary: Root Cause Analysis A. Aspects of Root Cause Analysis 1. Description of Sentinel Event Nightingale Community Hospital is conducting a root cause analysis of a pediatric abduction which occurred during a post-operative discharge process. “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events are called "sentinel" because they signal the need for immediate investigation and response.” (The Joint Commission, n.d.) In this event, a three year old child was admitted to Nightingale Community Hospital for a bilateral myringotomy. The mother of the child stepped out during the surgery in order to run an errand involving her other child. The mother was told the surgery would take about 45 minutes. The mother relayed that she should be back after the surgery to pick up her child. The mother did not respond after the recovery, even though the recovery nurse called out to the waiting area and paged for the mother. The patient was then transferred to the discharge nurse. The child was agitated waiting for her mother to return. Coincidentally, the father was at the desk and the nurse invited him to see his child. The nurse was relieved as the child changed her affect to one of excitement and called him daddy...
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...be leaving the hospital during the surgery to attend to a sibling matter at home. The mother left her cell phone number as the best contact number to call. This number was entered into the nurse’s personal notebook but was not entered into the patients chart. Post-surgery, the child was taken to the recovery area. The mother had not yet returned to the hospital. During the recovery period the child became more anxious without her mother at bedside. A male presented to the recovery area and identified himself as the child’s father. The patient identified the male as “daddy” and appeared to be comforted by his arrival. The father was provided discharge instructions by the post-operative nurse and was released to his care. Approximately 2 ½ hours later the mother arrived at the unit and was notified the patient had been discharged to home with her father. Mother became very upset, stating the she and the father were divorced and she was the custodial parent. At this point security was notified and a “code pink” was activated. Local law enforcement were also notified by...
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...¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼ ¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼¼ ¦ PAGE DATE CODE ¦ PAGE DATE CODE ¦ PAGE DATE CODE ¦ ¦ ¦ ¦ ¦ ¦ ¦57-05-05 ¦57-31-01 ¦ ¦CHAPTER 57 TAB ¦ 201 DEC 22/09 01 ¦ 401 APR 22/01 01 ¦ ¦ ¦ 202 AUG 22/09 01 ¦ 402 APR 22/02 01 ¦ ¦WINGS ¦ 203 AUG 22/09 01 ¦ 403 APR 22/02 01 ¦ ¦ ¦ 204 AUG 22/09 01 ¦ 404 BLANK ¦ ¦EFFECTIVE PAGES ¦ 205 AUG 22/09 01 ¦ ¦ ¦SEE LAST PAGE OF LIST FOR ¦ 206 AUG 22/09 01 ¦57-41-56 ¦ ¦NUMBER OF PAGES ¦ 207 AUG 22/09 01 ¦ 401 APR 22/05 09 ¦ ¦ ¦ 208 AUG 22/09 01 ¦ 402 AUG 22/01 01 ¦ ¦ ¦ 209 AUG 22/09 01 ¦ 403 APR 22/09 03 ¦ ¦57-CONTENTS ¦ 210 AUG 22/09 03 ¦ 404 APR 22/09 03 ¦ ¦ 1 DEC 22/09 AWW ¦ 211 AUG 22/09 03 ¦ 405 DEC 22/08 02 ¦ ¦ 2 APR 22/09 AWW ¦ 212 AUG 22/09 03 ¦ 406 DEC 22/08 09 ¦ ¦ ¦ ¦ ¦ ¦57-00-00 ¦57-05-06 ¦57-41-57 ¦ ¦ 1 DEC 22/06 01 ¦ 201 DEC 22/09 01 ¦ 401 APR 22/03 01 ¦ ¦ 2 DEC 22/01 01 ¦ 202 AUG 22/09 01 ¦ 402 AUG 22/08 02 ¦ ¦ 3 FEB 10/94 01 ¦ 203 AUG 22/09 01 ¦ 403 APR 22/03 01 ¦ ¦ 4 AUG 22/99 01 ¦ 204 AUG 22/09 01 ¦ 404 AUG 22/08 02 ¦ ¦ 5 AUG 22/99 02 ¦ 205 AUG 22/09 01 ¦ 405 AUG 22/08 02 ¦ ¦ 6 BLANK ¦ 206 AUG 22/09 01 ¦ 406 AUG 22/08 02 ¦ ¦ ¦ 207 AUG 22/09 01 ¦ 407 AUG 22/08 01 ¦ ¦57-05-03 ¦ 208 AUG 22/09 01 ¦ 408 BLANK ¦ ¦ 201 DEC 22/09 03 ¦ 209 AUG 22/09 01 ¦ ¦ ¦ 202 AUG 22/09 06 ¦ 210 AUG 22/09 01 ¦57-41-58 ¦ ¦ 203 AUG 22/09 06 ¦ 211 AUG 22/09 01 ¦ 401 AUG 22/08 03 ¦ ¦ 204 AUG 22/09 06 ¦ 212 AUG 22/09 01 ¦ 402 AUG 22/08 03 ¦ ¦ 205 AUG 22/09 05 ¦ 213 AUG 22/09 01 ¦ 403 DEC 22/09 02 ¦ ¦ 206 AUG 22/09 05 ¦ 214 DEC 22/09 03 ¦ 404...
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..."AFT" The New Business Theory by Joseph Barnhardt Strayer University, Professor Lind Contemporary Business Bus 508 Summer Term 2 Many successful business tycoons have created great business theories and or philosophies that been implemented and with stood the test of time in which their business are the model for many to follow today. So in thinking of a new business theory one comes to mind of ” AFT” which stands for Attention, Focus, and Thinking. Steve Case CEO of AOL.com used his own theory when he started his businesses in the early 1990‘s towards his success which were People, Passion and Perseverance. This logic of think has made his company what it is today a fortune 500 company and a major player in todays internet business market. In todays entrepreneurial leadership processing, new theories can be tried and proven effective or not. So beginning with the first word of AFT being attention, can be implemented in every business decision and planning you can become successful. Attention begins the fa major step in planning strategies or creating a plan of attack with the goals for leading your project from beginning to end. Webster defines attention as condition of readiness for such attention involving especially a selective narrowing or focusing of consciousness and receptivity (Webster, 2011). Attention is a very important piece of planing and decision making for any project to begin to come to fruition. The next piece of “AFT” is Focus, focus...
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...Accreditation Audit: AFT Task 3 Western Governor’s University Abstract AFT Task 3 allows the examination of data from a patient while hospitalized at Nightingale Hospital and utilizes a tracer methodology to identify trends, patterns, and pertinent problems for healthcare improvement. We plan to develop a corrective action plan to address the organization’s improvement while maintaining compliance from a Joint Commission standard. Accreditation Audit: AFT Task 3 Nightingale Hospital is preparing to devise a mock tracer methodology to assess the organizations’ current compliance with Joint Commission Standards. A tracer methodology follows a patient through the course of care and evaluates all aspects of care (Joint Commission E-dition, 2014). This method allows a quick overview of a patient through the flow of a system in order to evaluate the effectiveness of the process flow. Our mock tracer patient is a sixty seven year old female whom recently underwent an open total abdominal hysterectomy secondary to menorrhagia and uterine fibroids. The patient presented back to the emergency room one week postoperatively with complaints of a subjective fever of 100.2 degrees Fahrenheit and incisional drainage described as yellowish-green in color. A CT scan of her abdomen was performed in the emergency room and revealed a peri-umbilical abscess. The surgical team was consulted and an incision and drainage of the abscess was performed. Infectious disease physicians determined...
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...Miniature Aerial Vehicle – Airframe characterization R. Shivkumar, Hemendra Arya & K. Sudhakar Department of Aerospace Engineering Indian Institute of Technology Bombay Powai, Mumbai – 400076 e-mail: arya@aero.iitb.ac.in Abstract: Airframe design is an important step in the development of mini aerial vehicles. Airframe design means the shape and size of the aircraft. Issues related to mini aerial vehicle design are discussed in the paper. In this paper a case study of design of a 0.6 m fixed wing aerial vehicle is presented. This case study also brings out the requirement of various tools to conduct such an exercise. Introduction: Significant interest is being shown by academic institutions in research activities related to Remotely Piloted Vehicles (RPV’s) and Unmanned Aerial Vehicles (UAV’s). Flying platforms and their design with suitable payloads reinforce classroom education while exposing students to a host of flight related problems and issues of systems integration. There has been a long felt need to bring students, especially in the field of engineering, closer to the complexities and risks in dealing with actual systems. The Department of Aerospace Engineering, IIT Bombay has decided to make headway in this direction by developing remotely piloted aerial vehicles as experimental platforms[1]. The various disciplines required for such a design activity are aerodynamics, performance, structures, stability, control and propulsion. Each of these designs are different compared...
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...intention of these rules is to ensure the boats are as identical as possible in construction, hull shape, weight, weight distribution, equipment, rigging and sail plan. It is impossible to foresee every conceivable innovation which may be thought of in the future and to mention every suggestion that has been ruled illegal in the past. When considering anything in connection with the boat or its sails or equipment which is not within established practice in the Melges 24 Class or involves the use of a material not previously used or accepted by the class or is not clearly covered by the class rules, plans or specification, you must assume that it is illegal, and must obtain a ruling from the Class Technical Committee before attempting it. A.2. ABBREVIATIONS. A.2.1. ISAF. MNA. ISAF Member National Authority. ICA. International Melges 24 Class Association. NCA. National Class Association. ERS. The Equipment Rules of Sailing. RRS. The Racing Rules of Sailing. A.3. AUTHORITY. A.3.1. The international authority of the class is the ISAF which shall co-operate with the ICA in all matters concerning these class rules. A.3.2. Neither the ISAF, an MNA, the ICA, an NCA, the copyright holder or an official measurer is under any legal responsibility in respect of these class rules. A.3.3. The Copyright Holder shall be Reichel & Pugh Yacht Design Inc. A.4. LANGUAGE. A.4.1. The official language of the class is English and in case of dispute over...
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...Interpreting Laws and Court Decisions Interpreting labor and employment laws, as well as court decisions, can be a tedious task at best. The laws set in place are constantly changing and use language that is not easily deciphered by the average working American. The United States Labor laws cover the binding legal connection between the employers, their employees and the employee labor unions. Within the borders of the United States; it is generally know that employers and labor unions do not see eye to eye on most issues regarding labor and employment laws. Labor laws can address one of three different situations: “A union attempts to organize the employees of an employer and to get the employer to recognize it as the employees’ bargaining representative; (2) a union seeks to negotiate a collective bargaining agreement with an employer; or (3) a union and employer disagree on the interpretation and application of an existing contract between the two. Within these three situations, specific rules have been created to deal with rights of employees and employers.” (Labor Law, 2005) The third situation is often seen more times than not; thus creating an everlasting rift between the two parties. In the case study 1-1 of our text, Reinstatement and Back Pay Remedy for Illegal Discharge, it seemed like a common sense; open and shut scenario. My initial thoughts without any research had me thinking there was no way an employer would need to reinstate an unlawfully terminated...
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...AIRCRAFT STATUS BÁO CÁO TÌNH TRẠNG MÁY BAY A/C STS ETOPS B ADD Raised Date MEL Reference MEL Limit Concession Operation Limit Defect/ Event Description/ Additional Information A141 M X B1165 03-Aug-11 FAA8100-9 41548 FH (31/07/12: 40045 FH) AFT cowl skin LH T/R of LH ENG damaged. C/O temp repaired I.A.W EO 3141.11 B1226 16-Dec-11 25-20-01 NA Flex LT AT seat 1H, 4K, 4AC broken B1341 24-Jul-12 21-25-01-01 03-Aug-12 141-07-1/12, Date:02-Aug-12, Exp:08-Aug-12/Strictly follow conditions of MEL B777:item 21-25-01-01 Recirc fan 3SC + 3C + LDGs ASSY RPL From 06-Aug-12 to 27-Aug-12. 2. Server P/N:1303576-100 was robed to CLR ADD of A142 on 08-Aug-12. A142 S X B1105 AMM 49-11-00 CHK EVERY 90 APU HRS APU OIL CONSUMPTION NEED TO BE CHKD EVERY 90 HRS A143 S X B1225 09-Jun-12 25-25-02-01A N/A Seat 55K lock pin missing B1240 05-Jul-12 AMM 78-31-06-200-803 extend to 36917 FH (14/08/12: 36471 FH) LH thrust reverser thermal insulation on RH engine torn A144 S X B1265 26-Jul-12 38-10-01-01 23-Nov-12 Water gauge at AFT portable water service panel is damaged A145 S X A146 S X B1187 23-Jul-11 72-31-07 Next ENG overhaul 07 fanblade platform of LH ENG temp repaired with silicon rubber A147 S X B707 27-Oct-10 AMM 70-00-00-200-801 Next ENG overhaul 02 bolts at POS 06 & 09 o'clock of L/H ENG between LPT and turbin center frame broken B1020 09-Aug-12...
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...OPERATION OF MASS BALANCE Typically checks involve verifying that the static weight condition of component balances within a specified range. If the control surface has either too much weight ahead of or behind the hinge line, the control surface may flutter during flight. In extreme cases, flutter causes oscillations that progressively increase in amplitude, which ultimately can cause the pilot to lose control of the aircraft or could cause a catastrophic structural failure. The balance check is done with the control surface remove from the aircraft and assembled as specified in the manufacturer’s instructions. Generally all the mounting hardware and components contained within the control surface should be installed in their relative positions. Once assembled, the control surface is placed on balancing madrels within a draft-free room. The mandrels are positioned under the hinge points in a way that allows the control surface to pivot freely without dragging or binding. A balance beam or jig is then installed to determine the moment arm required to balance the control surface. The beam consists a graduated measuring scale in which weight can be moved to bring the control surface to horizontally level position or other position specified by the manufacturer. Once in the proper position, the distance that the weight is located ahead of or behind the hinge line is recorded and checked against the manufacturer’s specification. If the moment arm exceeds the manufacturer’s specification...
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...Accreditation Audit AFT Task 1 Roland Helmuth Western Governors University Accreditation Audit AFT Task 1 Medication Management A. Compliance Status I will be reviewing three specific areas dealing with medication management. They are the following with the correlating Joint Commission Standard following each one: 1. The hospital plans its medication management process, (MM.01.01.01). 2. Label all medications, medication containers, or other solutions on and off the sterile field, (NPSG.03.04.01). 3. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy, (NPSG.03.05.01). In review of standard MM.01.01.01, I see that Nightingale Community Hospital (NCH) has a policy that speaks directly to this standard. The elements of performance are met by the policy that is in place and includes further information to make this important standard compliant with Joint Commission standards. In review of standard NPSG.03.04.01, I do not find the NCH has a policy that addresses this. Seeing that NCH has surgical and sterile procedures performed at its facility this standard needs to have a policy in place. The basis of this is patient safety related to the five rights of medication administration; Right patient, Right medication, Right dose, Right route and Right time. Even in a controlled environment of a surgical suite, this is vital to any procedure performed. In review of...
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