Quality Assurance Meeting At Present

794 WordsJul 24, 20154 Pages
Quality Assurance Meeting At present, the convening of this group is to assess a particular never event that occurred in Huntsville Hospital last month. The National Quality Forum literally defines a never event as a preventable adverse event occurring in a health care setting that should never happen; like, wrong site surgery, patient falls, and medication errors as examples (Gitlow et al., 2013). Discussion, explanations and resolutions are the intended outcome of today’s meeting. Never Event On June 3, 2015, the staff in the cardiovascular surgical suite (CVOR) allowed a patient to fall to the floor when transferring the patient from the operating table to the patient bed, following coronary artery bypass surgery. Regrettably, the patient endured facial fractures, however, fortunately there was no harm to the surgical procedure on the coronary arteries, head, lungs, drains, chest tubes or anywhere else. Present in the surgical suite for the period of the incident included two certified nurse anesthetists, two scrub technicians, one registered nurse, and one physician’s assistant. Following the closure of the surgical site, the appropriate dressings were applied, the cardiothoracic surgeon left the surgical theater, and the patient was transferred to the patient bed when the never event occurred. Discussion The opinions of the physicians, staff and management present at today’s meeting exist as uncontrollable patient factors and controllable environmental factors.

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