Non Punitive Critical Incident Report

The objective of this case is to understand the importance of crisis management. This case is intended to make the reader consider not only financial implications at the time of the event but the effects on the long term strategies of the organization. Also, the case urges participants to think about the consequences not only on the customer but on those within the organization as well.

On August 9th, 2014 , Michael Brown, an unarmed black teen was shot and killed by a police officer in a St. Louis, Missouri, suburb. Following the shooting, the largely populated black city of Ferguson erupted into protests, forcing the U.S. Attorney General Eric Holder to make an investigation into the incident. Law enforcement nowadays has become a major problem lately, they have been arresting and murdering hundreds of black people, for crimes if a white person did, will receive different treatment. And, when black people are taken to court they are receiving unfair sentences because of racial profiling . Although much has changed in the United States over the past 60 years, this country’s legal system has failed at providing justice for

Developed in 1991, the National Incidental Based Reporting System was created to help keep better track of crime statistics collected by the law enforcement system by getting more information and asking for more details of each crime being happening. Unlike the Uniform Crime Reports System (UCR), developed in 1929, the NIBR system collects more information and uses a greater data procedural. NIBR system is a later branched off system from the Uniform Crime Report System. The National Incident Reporting System is made up of two groups, group A and group B. In group A, there are 22 offense categories that consist of 46 specific crimes, while The Summary Reporting System only has 8 offence categories and only the worst cases are reported. In group B, there are 11 offences but only consist of arrest information and statistics.

Research indicates that many organizations all over the world will be confronted because of critical events, which are likely to compromise the reputation of the organization (Nudell & Antokol, 2001). Due to this fact, planning on how to overcome its critical event in the face of

One factor that has led to discrepancies is the use of zero-tolerance policies in schools. Zero-tolerance policies picked up traction in the 1990’s and focused on the possession and use of drugs and weapons on school property. (Noll, Clashing Views on Controversial Education issues p.309) The Guns Free School Act of 1994 placed a one-year expulsion and referral to the juvenile court system for any student caught on campus with a weapon. (same as above) The debate on zero-tolerance has been centered on whether the policy has reduced violence in schools and if the policy is being used for the severest of offenses. In a 2014 address, Arne Duncan, then U.S. Secretary of Education, stated as many as 95 percent of school suspensions were for nonviolent

Within the public safety and criminal justice field, leaders depend on out stats from our reporting system about crime in their area or state. This data can be located on either the National Incident-Based Reporting System (NIBRS) or the Uniform Crime Reports (UCR) system that is published by the Federal Bureau of Investigation (FBI). These reports are helpful not only to public safety and the criminal justice field, but also to researchers. The reports can help a researcher gain ideas of areas that need to be studied (e.g. does a defendant’s neighborhood influence criminal activity, etc.). Within this paper it will discuss research that can help us to identify what type of

At Harvard School of Public Health, Lucian L. Leape discovered, that many patients appreciated several aspects of the post adverse event apology. The discovery also sheds light on the fact that most patients accepted the apology and did not consider suing. Patients have appreciated the apology that was given; which also was made known that," an apology gave the patient a sense of satisfaction and closure, which led to faster settlements and less demand for damages"(Hodge & Saitta, 2012). In addition, when a physician took on that responsibility it also displayed that they took ownership and created a sense of ease between the patient and care provider. When apologies are perceived as having feelings from a physician to a patient the patient

There are different categories of SREs and an example includes performing a surgery on the wrong patient and an example of product or device events is death resulting from use of contaminated drugs. (NQF Updates List of Serious Reportable Events and Identifies Applicable Settings).Defect devices received through a health care facility. SREs on surgical event can be prevented by ensuring that proper records of patient are kept by a qualified staff, and also care and due diligence is observed when the process is taking place in that a small error may result to death which is very adverse. The strategies to be used if it ever happens is that the health care facility should be conducting forums whereby care and due diligence

The person who committed error also feel anxiety and fear about patient and their family member’s pessimistic behavior (Koohestani & Baghcheghi, 2008). Another reason for underreporting of patient safety incidents is poor knowledge about organizational incident reporting system. Whereas, some health practitioner thinks it takes extra time for recording an adverse event accurately (Journal of Psychiatric and Mental Health Nursing, 2014).

The presented case for this unit discussed the challenges that Leman Healthcare has been met with in getting their employees to utilize a costly incident-reporting system. The new system, which was deployed across the entire Leman system, allowed physicians, frontline and management staff to more effectively and efficiently access patient records as well as document and report adverse events to senior members of the management team, risk managers and the Quality Improvement (QI) Department (Burns, Bradley & Weiner, 2011). Following the deployment of the new system however, Leman Healthcare staff noticed that overall even with the introduction of the new incident-reporting system, QI practices throughout the system as a whole had not changed.

Reflective Practice within Nursing has been defined ‘as a process that develops understanding of what it means to be a practitioner’ (Rolfe, 1998) and follows on with the ‘theory and practice through the practitioner consciously thinking through the experience’ (Jasper, 2003). This is of great importance regarding a practitioner, especially one in learning, as they are able to develop a better understanding of their role and offers support when learning new skills. In Nursing, Reflection plays a huge role. Most of the opportunities to learn and develop knowledge come best when learnt through practice and subsequently will be found in a practice environment.

Incident reporting is very crucial for improving the safety and quality of patient care. It allows healthcare organizations to investigate the contributing factors of adverse events and help them to develop potential solutions. In my workplace, we use an incident report form and Situation, Background, Assessment, and Recommendation (SBAR) form, where all the information related to an incident including possible cause are incorporated and then forms are submitted to the unit manager. Unit manager reports an incident to the director of nursing (DON) and DON and the facility administrator start investigation and interventions. Finally, a healthcare worker who was involved in an incident should take in-service education in that particular area

This scenario can be applied to all types of services regardless of their size. As the scenario states, many services chose to handle when they are reported often with knee jerk type reactions. It is for this reason that many employees are scared to report mistakes because of the threat of termination for the individual involved. These acts then create the other victims in addition to the employee being punished.

Two weeks ago, there was an incident at Truss Construction Shop. A hoist operator was placed into an induced coma due to a large part of a Truss breaking apart during a QA Truss load test. The Truss broke apart because the testing was pushed beyond the threshold. This incident made the employees worry that the trusses would fail underloaded. The sales department is concerned about customers cancelling orders because of delays in shipping. A cancelled order creates an unsatisfactory customer, which can affect sales tremendously. Another issue arising from the event is that a worker named Faruch Habib leaked the details of the incident and the testing outcomes of the QA Truss load

Incident reporting mechanism is an essential component in nursing occupation that facilitates the identification and monitoring of adverse events or incidents that occur during health care service. It is a defined procedures and protocols that should be place and disseminate throughout the organization. The reporting system is used to report occurrence such as falls, safety issues for patients, medication errors, treatment and procedural problems, and malfunctioning equipment. The benefit of incident reporting mechanism is to protect patient from injury or harm. In order to maximize patient safety, adverse events, mistakes and errors, and near misses incidents should be report in a timely and accurate manner. Furthermore, it is also used to make the nurse aware of inadequacies of her own part which make her reflect upon the situation and how this could be learned from, so as to prevent making same mistake again.