Sample Sentinel Events

Improving the quality of discharge planning in acute care include addressing the lack of appropriate staff and patient education about appropriate planning for discharge (4). This includes implementing proper discharge teaching regarding signs and symptoms to seek medical attention, management and care of medical equipment, and access to community resources (4, 5). Other challenges are patients with complex comorbidities too difficult to discharge as well as lack of community supports and equipment for newly discharge patients and lack of rehabilitation and nursing home beds (4). Consequently, acute care units are pressured to vacate hospital beds in response to the growing elderly population. Hospital professionals tend to focus discharge teaching and preparation on medical areas such as diet, activity, treatments, and medications (5). Community referrals to appropriate services at the time of hospital discharge does not often happen contributing to poorer patient outcomes and re-hospitalizations

Discharge planning is used to create a plan of care for a patient who is leaving a care setting. An evaluation is done to determine the patient’s continuing care needs once they have left the care facility. When patients are send back home or to a facility that does not require full time nursing care assistance, programs need to be put into place to ensure that the patient is receiving the proper continuation of care post discharge. Proper discharge planning can decrease the chances of a hospital readmit, help in recovery, ensure medications are prescribed and given correctly, and adequately prepare family or caregivers to assume proper post discharge care. According to the Family Caregiver Alliance, “It is important, not only for patients, but family

In 1974, the federal government adopted the Uniform Hospital Discharge Data Set (UHDDS) as the standard to help improve the uniformity and comparability of hospital discharge data, the principal diagnosis, and other diagnoses for hospital procedures; including comparable data that could help to determine which hospitals were best at treating patients and for reporting inpatient data in acute care, short-term care, and long-term care hospitals. This dataset works towards a standardized system of reimbursement for the federal government nationwide which in turn could lower costs, UHDDS helps in collecting general information pertaining the patient and the specific care including the age, sex, and race of the patient. The data elements are collected

This sentinel event involves child abduction from the surgical unit of Nightingale Community Hospital on Thursday, September 14, 2014 at approximately 1230hrs. The patient, a three-year old female, arrived accompanied by her mother, for an outpatient surgical procedure at 0800hrs and proceeded to registration where all currently required documentation was completed and signed by the mother; this included the authorization forms for the surgery. After registration, the patient and her

This sentinel event is directly associated with a child abduction at Nightingale Community Hospital. A 3 year old patient was having surgery at Nightingale Community Hospital on Thursday, September 14. The patient’s mother accompanied the patient before surgery and completed all consent form. An estimated time of 1 hour 45 minutes was given as the time to complete surgery and recovery. The mother informed the pre-op nurse that she would be off campus during the surgery and would return to pick up the patient in the time frame given. She also provided a phone number to

Ineffective discharge teaching often leads to unnecessary admissions to the hospital resulting in negative patient outcomes and decreased patient satisfaction. This negatively impacts the well-being of the patient and creates a financial burden on institutions. As a result, this universal practice issue requires a call to action on the part of the nursing profession. Nurses can proactively assist in assuring incidents of readmission do not occur. Nurses as educators play a critical role in the successful transition of patients from hospital to home. The overall goal of discharge education is to ensure there is an exchange of critical information between the patient and nurse in which plans of care are understood and followed. The research

Standard 16 of the American Nurses Association (ANA) Scope and Standards Practice, directs nurse leaders to advocate not only for patients but for all members of our healthcare community. As a discharge planner, I am in a unique position to advocate not only for patients but for caregivers as well. As part of my responsibilities, I participate in daily multi-disciplinary team rounds. The meetings take place so that all disciplines can openly discuss patient care needs. They provide the perfect opportunity for anyone to bring to light problems or concerns.

The purpose of this BSR project is to assess the nurse’s performance during their handoff report and develop some strategically possible solutions that may improve a patient quality of care, safety, and satisfaction. Communication plays such an important role between nurses and patients to emphasize that an “Effective workforce planning and policymaking require better data collection and an improved

Hospital discharge has been defined as “a systemic problem that can be characterized as a dangerous situation in which latent conditions exist such that sharp end individuals are set up to fail” (Anthony et al., 2005). Understanding this process is flawed warrants an investigation for a change in practice. Research has explored a variety of interventions that address reducing 30-day readmissions such as post-discharge phone calls, RED toolkit, BOOST toolkit, transition coaches, and home visits after discharge. Despite these tools, 30-day readmission rates among the older adult population continue to be a challenging issue.

In light of the recent events, the most stated issue staff had was lack of communication throughout the entire facility among other staff members as well the referring provider’s offices. There was also a concern for the lack of policy regarding the check-in and discharge process for the safety of our pediatric patients. A few staff felt as if they had too many duties to be worried about any more and it should be the responsibility of other staff members to be concerned with the discharging of a pediatric patient. By not properly putting policies in place for a thorough patient in-take and patient discharge process, it not only jeopardizes the well being of the patient, but it poses a legal liability on us for many privacy violations. These barriers fail to promote proper communication with appropriate departments and leaves each department to make inconsistent judgment in situations such as the most current sentinel event. Of all the employees interviewed during the said event, most stated that they had no way of knowing they were making the wrong judgment. For instance, verifying patient’s parents upon arrival as well as approval of who is allowed to have access to the

If this scenario happened in an outpatient clinic or urgent care center and there were physicians who were more dedicated to patient safety a report to child protective services may have been made regarding the child’s injuries. This child deserves to have her rights observed and

that resulting in the adverse event.The last step is devising recommended actions or place to prevent recurrence of the sentinel event.This steps results with developing and implementing interventions to improve and prevent the adverse event from recurrence.

Patient discharge time refers to various activities that begin with the specialist signing the order for discharge and summed up with the patient when leaves the hospital. The title of the case suggests that there is always need to focus on the improvement of the patient discharge time. In this case the six sigma approach or model was used. In the article , the process of discharging a patient, that is from the hospital is described which is considered as a critical process in healthcare, this usually begin with the specialist signing the discharge order , then the end is the process is seen when the patient leaves the hospital. There are some order for the discharge order before the specialist pens down the signature; this starts with the resident documenting a report, then followed by a nurse, the clerk records data for the discharged patient within the information management system of the hospital. After all the signatures and book keeping is done through various departments, the files are presented to the accounting department where now the patient heads to pay. In order to reduce failures in

Discharge planning and management with an elderly person can become very complicated and should be approached with an open mind and the willingness

Discharge Planning – Patients who require continuing care after release from the hospital are identified and the appropriate services are arranged through participating home care, medical equipment and other providers.