Service Line Development

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

Karen could not identify potential risks, she heard about problems and a task force member told her of problems but she did not do anything about it or try to put measures in place to rectify the problems. After four months she asked in a meeting what the problems were, she could not identify it herself.

In getting all parties involved to work as part of an integrated team, the risk identification process would have involved a larger number of people and increased the identified sources of risk for the project. This fundamental relationship between project parties played a huge role in the success of the project with regards to time and cost. (Davies et al, 2009)

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.

Sentinel event refers to the occurrence of serious physical illness or death or psychological injury or even those incidences whose recurrence involves risks with adverse and serious outcomes. It may result into deaths that are not anticipated or permanent loss of a major function that is not associated with patient’s natural cause of illness or condition (Lewis et al, 2014). The causative factors of Mr. B’s demise, according to the scenario described are that Mr. B was not put on oxygen or an EKG monitor

This paper will analyze the cause of the sentinel event which occurred to Mr. B, a sixty seven year old patient which presented to the emergency room with left leg pain. A root cause analysis will be necessary in this case to investigate the causative factors which led to Mr. B’s sentinel event. The factors in this unfortunate case weather they were errors in his care, or hazards in the system will be identified. The Change theory will be used to develop an improvement plan that will be used to decrease the chances of a reoccurrence of the sentinel event that happened to Mr. B. in the scenario.

This assignment will look at incidents and emergencies that can happen in a health and social care setting. Within my assignment I will be explaining possible priorities and responses when dealing with two incidents or emergencies in a health and social care setting. I will be discussing

A root cause analysis is a systematic approach utilized to identify problems within an event and create a plan for preventing that problem from recurring in the future. To be effective, a timeline of the events are created to help identify those areas that may be the reason for the problem or event, and the relationship between the causal factors and those factors identified to be a reason for the event to have occurred.

When analyzing the community health assessment several risks and weakness are identified. There are a few risks and weakness with the current state of Oncology Services. With physicians practices already at capacity there is no room to handle the current and future demand for these services. With an aging population new cancer cases are expected to increase by 34 % in five years. Higher smoking rates also contribute to new cancer diagnosis. Another risk is the equipment to diagnose and treat cancer is not keeping up with patient volume. This could be due to antiquated equipment that takes longer to scan patients therefore delaying results and sometimes requiring additional scanning. Additionally, poorly coordination of services by

“A central tenet of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals” (AHRQ, 2012). The emphasis of RCA is on error prevention. It is a structured process of gathering data regarding the event, analyzing the information, and finding solutions to the problems to prevent reoccurrences. A

Root cause analysis (RCA) is used in different fields to conduct a systematic search to find the causes of a specific sentinel event (Jacob, 2010).  The main goal for conducting a RCA is to prevent similar adverse events from happening in the future (Jacob, 2010).  In this paper, I will use the scenario provided in the task to create a complete RCA report as well as improvement plans that will prevent similar incidents from happening again.

Taking time to conduct a proper analysis of the cause eliminates a premature conclusion that may lead to inadequate corrective actions (William, 2008). A root

Ogrinc, G., & Huber, S. Institute for Healthcare Improvement, (2013). How a root cause analysis works. Retrieved from Institute for Healthcare Improvement website: http://app.ihi.org/lms/lessondetailview.aspx?LessonGUID=95d54b96-7750

Then the team needs to investigate the issue clearly as fast as possible because time is as

The case study I chose to analyze was the Space Shuttle Challenger Explosion by Ronald C. Kramer. Kramer discussed four main components that led to the catastrophic explosion. These components include the societal context, the final flaw, the persons behind the final decision to launch, and lastly the failure of social control mechanisms. There was not just one factor that led to the failure of the launch. As Kramer discusses the different concepts that led to the failure point to state-corporate crime as a private business and government agency interacted.