Root Cause Analysis Due to Sentinel Event Essay

New study finds U.S. hospitals must improve workplace communication to reduce medical errors, enhance quality of care. (2005, Jan 26).U.S.Newswire. Retrieved 3/8/12 from, http://search.proquest.com/docview/450869420?accountid=458

Searches were made through the online library at Grand Canyon University. Results were refined to include on peer reviewed studies with keywords as combinations of: Safety briefing (45 results), patient safety plus nursing plus communication (1769), patient safety and interdisciplinary (45). Of the results obtained, the list was further refined to those studies that discussed the issue of communication in a team environment and risk of errors, or leadership follow up. Studies were not included if they were considered to be out of scope for the issue. Ultimately ten articles were identified as being pertinent to the subject, or had conclusions that could be extrapolated to the issue in question. From these search results four studies have been chosen for this paper to support the relevance of the issue.

The patient was initially admitted due to terminal cancer, his family wanted him to have a procedure, but he elected not to do so due to the risk of being in his mid-eighties. Instead, he remained in the hospital for comfort measures because the pain was unbearable without medication. His son did not accept the fact that his father was dying and this created family arguments about the care of the patient because the family did not believe the patient knew what he was doing by declining treatment.

Several errors and hazards can be identified as possible factors leading to the sentinel event. The ER appeared to be terribly understaffed that day with only one ER physician, one RN, one LPN, and a secretary.

Fostering teamwork and engaging direct care nurses can have a real impact on patient safety and decreasing complications. By utilizing shared governance, councils at Cedars Sinai were shown to decrease patient falls and acquired pressure ulcers. Increased communications allowed for successes found at one unit-based council to be shared to improve outcomes system-wide (Swanson & Tidwell, 2011). Additionally, promoting a culture where underperforming is not acceptable helps to improve

3) Surgeon: Was directly involved in the events leading up to the sentinel event. The surgeon was responsible for all activities taking place in the surgical suite and directly related to the surgery of the pediatric patient. The surgery was completed safely and successfully; however, the surgeon had relevant information in the patient chart at his office yet did not share this information with the hospital. He also did not supply an appropriate or accurate H&P that would have included custodial status for the pediatric patient to the hospital. The surgeon is greatly concerned in the events that lead to the sentinel event and wants to ensure that his patients will be cared for and safe at Nightingale Community Hospital.

In preparation of a review from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Nightingale Community Hospital will focus on improving its communication process in the operating room. The purpose of communication in the healthcare setting is to disseminate information in such a way as to create shared understanding about the patient and about what needs to be done for a positive outcome. (synergia.com) A patient is at his most vulnerable state during procedures that require sedation or anesthesia. The patient is releasing his decision making ability and safety into the control and care of the healthcare team. Therefore, effective communication on behalf of the patient is

The pre-op nurse did not pass the information on when giving report to the OR nurse. The OR nurse is responsible for giving addition hand off information both about the patient along the information from the procedure she all so communicates with the surgeon during the procedure. It was during this interview that some insight about a breakdown in communication between departments became apparent.

Communication promotes knowledge within a health care organization and is necessary for the organization to thrive. Communication is not only important to the staff but also to the patients within a health care facility who depend on staff communication to receive quality medical care. Without complete communication between staff member’s clinical errors can occur and the patient’s health could be at risk. In this paper the subject will explain how a health care organization shares knowledge through communication and examine, which are the most effective techniques and which techniques are ineffective. This

Horkan, A. M. (2014). Exploring the Evidence Alarm Fatigue and Patient Safety. Nephrology Nursing Journal, 41(1), 83-85.

A weakness in communication between interdisciplinary team members can impact patient safety and health . A recent study revealed that out of all the claims analyzed , 57 percent of malpractice cases reflected miscommunication between two or more healthcare providers (Riah, 2015). In fact, the same communication failures directly linked to 1,744 deaths over the past five years (Budryk, 2016). During my clinical placement this semester I have witnessed the overwhelming number of health care team members that are involved in each patient’s care. I also take part in morning nursing rounds where all nurses are updated on every patient’s status. Transmission of permanent patient information is also relayed to all members of the health team via the patient chart .Here , interdisciplinary notes all come together to form updated health information on patients. However, although I have read interdisciplinary notes from all team members , I rarely have had the opportunity to personally communicate with members other than doctors and nurses. Personal communication allows for a team member to pass on relevant information in a timely manner without the possibility or misinterpretations. When communication is strictly done non-verbally, it is impossible to ask any questions.. This is why communication between professionals in health care is essential for patient safety and improved quality of care (Koivunen, Niemi., & Hupli,2015). There are 3 main factors that cause miscommunication

Open communication is essential part to a successful healthcare team that directly impacts patient’s lives. In the video “Just a Routine Operation, ” by Laedal Medical Human Factors in Patient Safety, physicians and nurses demonstrates how different human factors contribute to the overall outcome of the patient. Elaine, the patient in the video came into the hospital for a reconstruction surgery. However, during the surgery Elaine had a complication and because the lack of communication, assertiveness, self-awareness, decision-making, teamwork, and prioritization, Elaine did not survive the surgery. This situation shows how important these characteristics are when dealing with emergency care. Even the health care professional with the years

A noticeable issue was that medical abbreviation used by the doctor were not understood by others members of the team. This led to interruption of his speech to find out about their mining. This is mainly related to the fact that

Teamwork and communication are very important in providing good quality care, especially in the healthcare field. A team is described as a group of people that works together and cooperatively, between each member of the group to reach a common goal (Sullivan, 2013). For a team to function, communication is essential. A report by McKay and Crippen (2008), as stated by Alfaro-LeFevre, (2013) showed that when collaboration is in place, hospitals can decrease their mortality rate by 41%. When mortality rate is lower, hospitals does not only decreased cost, but it also means that patients are receiving good quality care.

Teams working in a hospital or other healthcare setting may consist of several physicians, nurses, medical assistants, referral coordinators, pharmacists, therapists, and students among others. Such large teams can provide comprehensive care for complex and chronic illnesses, but when they fail to work well together, they