...ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS 1 October 2012 – 30 September 2013 HOSPITAL AUTHORITY HONG KONG 1 ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) ACKNOWLEDGEMENT This is the sixth Annual Report on Sentinel and Serious Untoward Events. By continuously learning from sentinel and serious untoward events and by building safe systems, processes and practices to mitigate the recurrence of such events, it demonstrates the Hospital Authority’s commitment to quality and patient safety. We would like to take this opportunity to acknowledge all frontline staff, nurses, clinicians, risk managers and executives for their immense dedication and support in improving patient safety in recent years. Without their invaluable and incessant efforts in planning and executing various improvement initiatives to enhance patient safety through risk identification and mitigation, the publication of this annual report would not have been as meaningful. Patient Safety and Risk Management Department Quality and Safety Division 2 ANNUAL REPORT ON SENTINEL AND SERIOUS UNTOWARD EVENTS (1 October 2012 – 30 September 2013) TABLE OF CONTENTS Executive Summary 4 CHAPTER 1 – Introduction 9 CHAPTER 2 – Sentinel and Serious Untoward Event Policy 11 CHAPTER 3 – Sentinel Events Reported from 1 October 2012 to 30 September 2013 13 CHAPTER 4...
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...A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in rootcause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated. Contents * 1 Specific Events requiring review * 2 Actions and reporting * 3 Joint Commission actions * 4External links * 5 Notes | Specific Events requiring review Besides "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof", sentinel events also include the following, even if the outcome was not death or major permanent loss of function: * Infant abduction, or discharge to the wrong family. * Unexpected death of a full term infant. * Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter). * Surgery on the wrong individual or wrong body part. * Surgical instrument or object left in a patient after surgery or another procedure. * Rape in a continuous...
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...Legislation, and Implications to Patient Care Abstract There are constant changes to laws and legislation regarding patient care and safety. The purpose of this report is to inform the reader of recent and upcoming changes to legislation that may affect nursing care of patients. Research by L. Aiken, et al. and A. Tourangeau, support the need for higher education of registered nurses. Their research proves that patient outcomes are improved when registered nurses carry a bachelor’s degree in nursing. Research conducted by J. Needleman, et al., concluded that reducing the nurse-patient ratio resulted in the patient being at less risk for developing hospital-acquired illnesses as well as a reduced risk of inpatient mortality. The reader will also be informed about the Joint Commission’s protocol for reducing the occurrence of wrong-patient, wrong-site, and wrong-procedure during surgical procedures. Politics, Legislation, and Implications to Patient Care As the American population ages, healthcare and its resources are in greater demand. As the demand for healthcare increases, the topic of patient safety has become increasingly important. Laws and legislation regarding patient care are changing almost constantly to maintain patient safety while still providing comprehensive patient care. This report will focus on informing the reader of recent and upcoming legislation regarding patient care, what has brought those changes about, and the effects it can have on the...
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...Reducing Risks of Child Abductions at Nightingale Community Hospital A sentinel event in the hospital is an unexpected occurrence that involves or poses a high risk for death, serious physical injury or severe psychological damage (Joint Commission, 2013). Incidences that lead to adverse outcomes necessitate immediate attention and plans of actions to prevent recurrences. The Joint Commission, a non-profit certifying body for healthcare organizations, sets safety and quality standards for hospitals. It requires hospitals to conduct root cause analyses (RCA), implement processes to reduce risks of recurrence and evaluate the effectiveness of those processes for sentinel events (Joint Commission, 2013). Nightingale Community Hospital (NCH) had a child abduction sentinel event. The legal guardianship of a child who had surgery was not communicated to various departments of the hospital. The parents of the child were divorced and the mother had legal custody. The child was discharged home with her father. Fortunately, law enforcement located the child at her father’s home and no charges were filed. National statistics show that 9% of missing children are abducted by family members and 3% are kidnapped by non-family members (Polly Klass Foundation, n.d.). Less than 1% of abducted children are victims of homicide, physical abuse and/or sexual assault (Polly Klass Foundation, n.d.). Although these percentages are very low, the impact is great! This means a child who is abducted...
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...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 involving the possible abduction of a pediatric patient. As per reported, September 29th a three year old patient come to the hospital for a surgical procedures, accompanied by her mother. During the registration portion of the process the mother completed all the registration paperwork that was required. Along with authorization document, the patient was then directed to the pre-op area where the pre-op assessment was completed. It was at this time the mother informed the per-op nurse that she had several errands she needed to run while her daughter was in surgery, but she would be back to pick her up. The mother asked that if she had not return by the time her daughter surgery was completed to please call her mobile phone, and gave the pre-op nurse...
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...Sentinel Event: 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. Summary of the Sentinel event in the Case Study: Sentinel event presented in the case study involves discharge of a minor to the wrong family. Joint Commission requires immediate attention to such matters so that it may be avoided in the future. The summary of the event is that a 13 year old teenager, Tina, was admitted for day surgery. Tina was accompanied by her mother. After dropping Tina for the surgery at the hospital, her mother left to run some errands. Before leaving, she left her contact phone number with the pre-op nurse. After the surgery, Tina was inappropriately released to her father when her mother was delayed in returning to pick-up the daughter from the hospital. The hospital staff had no awareness of the family situation. Upon arrival at the hospital after the errands, mother was informed that Tina’s father had picked up Tina from the hospital because...
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...A.1: Description of the Sentinel Event At about 12:30 PM on Thursday, September 14th, a sentinel event occurred that involved a potential child abduction. Tina, a 3 year old child, was scheduled for a routine, same-day surgery at Nightingale Community Hospital to have ear tubes put in both ears. Tina was brought to the hospital by her mother, who had recently been divorced from Tina’s biological father; Tina’s mother has full custody of the children, including Tina. After Tina was registered and taken to the pre-op area of the hospital, the pre-op nurse informed Tina’s mother that the actual surgery would take approximately 45 minutes, and then Tina would need to stay in recovery for at least an additional hour. Tina’s mother informed the pre-op nurse that once Tina had gone to the operating room, she would be leaving the facility to run an older sibling on an errand, but she would be back to pick up Tina after she was released from recovery. The mother gave her cell phone number to the pre-op nurse, who wrote the phone number down on a note-pad the nurse carries in her pocket. Tina’s mother asked for the nurse to call her on her cell phone if Tina’s procedure was completed sooner than expected. When Tina was taken into surgery, the mother left the facility to run her errand. After the surgery was completed, Tina was taken to post-op to recover. The recovery nurse paged Tina’s mother, but did not receive a response. Tina was transferred to the Ambulatory Care nurse...
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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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...Sentinel Event A mother brought her child name Tina to Nightingale Community Hospital for a procedure. The pre‐op nurse informed the mother of the time line for the surgery. The mother had some errand to do involving an older sibling and made the nurse aware of it but would return in time to pick up Tina. To stay informed, the mother gave the pre‐op nurse her cell phone number with instructions just in case Tina got out of surgery sooner than expected. Approximately 2 ½ hours later, the mother returned and her child was already discharge 30 minutes earlier to the child’s father without the mother’s consent to the hospital. At this point, hospital security was called, and hospital‐wide child abduction alert was activated. It is apparent that there is a break down in any process that the hospital may have. Since they were able to release the child to someone that claims to be the father, it is clear that there is a flaw on how the hospital handles this process. The following personnel were interviewed individually during the sentinel event: 1) Tim Blakely, Officer. At 09:00, Officer Tim received a call and was informed that there was potential child abduction. He immediately went to interview the nurse who stated that a child was missing from the facility for approximately 25 minutes. Office Tim questioned why the call didn’t come earlier and believe that if they performed more drilled, the event could have been prevented. 2) Katie Jessup, Registrar. Patient information...
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...For over a year, and $26 million over budget, the FBI’s computerized Sentinel case management system is finally up and running (project was expected to be completed in September 2009 but took 2 years extra (2011) to complete), according to reports. The project started in 2006 with a $425 million budget and after several delays; it was showcased on March 2012. Sentinel, is a digital records storage system that was designed to replace old fashion paper files. The program is also a web-based interface for the FBI employees to use to gather up documentations and reviews. The systems user interface was described as an appearance similar to Microsoft’s outlook email with event calendar, and RSS feeds for keeping up to date with changes to case files and search engines. The initial bill for the project was supposed to be $425 million but ended up costing $451 million. Sentinel was supposed to be up and running since 2009 but problem arise such as Lockheed Martin's role as the prime contractor being reduced, complaints from the Justice Department and IT related issues, the project got delayed by many months and is finally up and running. Some lessons learned from the article are that one should not deploy new software on old hardware. According to one of the articles, during a four hour test, 743 users suffered two outages. The mistake was that the agency ran the test on the legacy hardware which was then forced to upgrade to a rollout. This caused many delays. Another lesson learned...
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...A. The sentinel event was related to respiratory arrest secondary to conscious sedation procedure. There were several factors that played a role which included high patient census, poor staffing, alarms dismissed by staff members, patient was left unmonitored, and no supplemental oxygen initated prior to the procedure. When the patient was pulseless no CPR was initiated until the code team arrived and critical interventions were delayed by the emergency room staff. The patients medication reconciliation or history weren’t reviewed by the emergency room physician. Tripple doses of intravenous valium and dilaudid were given without a lapse in time. The patient was elderly and on chronic oral opioid medications. “Normally these types of medications are administered with low doses and titrated per patient’s sedation level. Patient, monitoring or sedation level weren’t assessed between doses. This event is known as a sentinel event. In any situation that causes injury, or death a root cause analysis must be completed and reported to the Joint Commission. B. To implement a change in the conscious sedation procedure a team or committee needs to be established. All staff in the emergency room can become active participants by joining a committee or subcommittee. These main categories may include patient characteristics, task factors, individual staff members, team factors, work environment, and organizational management (IHI, 2014)...
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...organization identifies key indicators to monitor the clinical structures, processes and outcomes • Objective elements a) Monitoring includes appropriate patient assessment. b) Monitoring includes diagnostics services’ safety and quality control programmes. c) Monitoring includes all invasive procedures. d) Monitoring includes adverse drug events. e) Monitoring includes use of anaesthesia. f) Monitoring includes use of blood and blood products. g) Monitoring includes availability and content of medical records. h) Monitoring includes infection control activities. i) Monitoring includes clinical research. CQI.3 The organisation identifies key indicators to monitor the managerial structures, processes and outcomes Objective elements • Monitoring includes procurement of medication essential to meet patient needs. • Monitoring includes reporting of activities as required by laws and regulations. • Monitoring includes risk management. • Monitoring includes utilisation of facilities. • Monitoring includes patient satisfaction. • Monitoring includes employee satisfaction. • Monitoring includes adverse events. • Monitoring includes data collection to support further study for improvements. • Monitoring includes data collection to support evaluation of the improvements. CQI.4 The quality improvement programme is supported by the management • Objective elements a) Hospital Management makes available adequate resources required for quality improvement...
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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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...Clinical Issue Article - Step 4 The working patterns of the Registered Nurse (RN) have caught the attention of researchers in the last 15 years. The mounting evidence illustrates a direct correlation between long working hours and poor patient outcomes as evidenced by an increase in patient errors, near sentinel events, and injuries to the nurse. The sentence outline is a clear and concise method of uniting the original study question of patient quality care outcomes directly affected by nursing hours worked and the major facts of the research evidence to support the conclusions and findings of the study. I. Clinical Issue Chosen: PICO format a. Problem/Population of Interest i. Registered nurses care for patients in a variety of settings, including hospitals that require 24-hour nursing coverage. ii. Does an RN working eight- or 12-hour shift create potential hazard to patient safety? b. Intervention of Interest i. Nurses who work eight-hour shifts do not cause an increased risk to patient safety. c. Comparison of Interest i. Nurses who work 12-hour shifts may increase the risk of errors and may potentially negatively affect patient care. d. Outcome i. XXXXXXX I don’t know what to put here… I’ve struggled with this part all along. I don’t know what it is????? II. Literature Search (Quantitative) a. Extended work shifts may predispose nurses to make more errors. i. Evidence supports that nurses working beyond a 12-hour shift may directly affect patient mortality...
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...As per Joint Commission standards Nightingale community Hospital is reporting within 45 days a Sentinel Event that occurred at our hospital last week. To summarize this event; 3 yr old T.G. was admitted to the Ambulatory Surgery Unit (ASU) for a routine procedure with Dr. Carlos Munoz. After a brief visit with the registrar to fill out all appropriate paperwork the patient and her mother waited in the pre-admission area. The patient and her mother were then called into pre-admission. The Pre-operative nurse proceeded to go through the standard steps prior to being taken into surgery. According to the nurse an assessment was completed, the patient was changed into a surgical gown, and her belongings taken care of. An IV was started, appropriate labs were drawn, the informed consent was signed and information about the length of surgery and recovery time were discussed with the patients mother. The mother stated to the pre-operative nurse that she would be leaving the hospital to attend to another child, she left her cell phone number with the Pre-Operative Nurse who proceeded to write this number into a personal notebook that she carries. The specific instructions to the pre-op nurse were to call the mom when the surgery was over. At this point the patient was ready for surgery, at the appropriate time the patient was taken to surgery and care transitioned into the care of the OR nurse, surgeon and the OR staff. Upon completion of the surgery the patient was transferred from...
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