Root Cause Analysis
A.1 Sentinel Event 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
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There was no hand off of the cell phone number the mother provided to the pre-op nurse. As there is no documented area on any of the forms for this information, the process relies on verbal handoff and memory of the nurse. There was no alternate phone number available for the nurse to contact the mother or other designee. Recovery Nurse – The patient was transitioned from the operating room to the recovery room. As previously noted, there is no formal hand off process from one area to another within the ambulatory surgical center. The recovery nurse attempted to locate the mother in the waiting area. As noted above, there was no hand off of the mother’s cell phone number or alternate contact information. Discharge Nurse – The recovery nurse brought the patient to the discharge are post recovery. The patient’s mother had still not returned to the hospital. Again there is no formal hand off process to exchange information. The patient was reported to be anxious and crying. A call was received reporting the patient’s father was available in the waiting area. The male was brought to the area and the child was reported to appear comforted by his arrival. Discharge instructions were given and the child was released with the father. There was no reported verification of photo identification. None of the forms in the patients chart identified the father as the contact. There was no verification the male was
The disease process I will be reviewing is traumatic brain injuries. A traumatic brain injury occurs when sudden trauma occurs to an individual’s brain. Traumatic brain injuries are considered closed or penetrating. Traumatic brain injuries are categorized as mild, moderate or severe based on the amount of damage that occurs to the brain. (ninds.nih.gov, 2015)
Cognitive Development refers to the construction of the thought process that includes problem solving, remembering and the ability to make decisions, from childhood up to the adulthood stage. Cognitive/Intellectual Development is the ability to learn, reason, and analyze the fact that a process begins from infancy and progresses as the individual (Educational Psychology). Cognitive Development contains events that are logical, like thinking and remembering. Some factors remain the same throughout many of the theories on cognitive development. All theorists agree that people go through specific steps and/or
A. Nurse sensitive indicators are factors that are directly impacted by nursing. There indicators fall into three categories; structure, process and outcomes of nursing care. The structure indicators are the organizational piece of nursing care. These relates to the amount of staff on duty at a given time, how many RN's are on duty and experience level of the staff. For example, evidence indicates institutions with a higher number of RN’s possessing a Bachelor Degree in nursing result in improved patient outcomes. The process indicators measure nursing care such as patient assessment, patient care and intervention. These are the organizational policies and procedures of nursing. The patient outcomes are indicators directly related to
The Utah Symphony has been a leading arts organization in the western part of the United States for decades. They have a rich, long history. Many strengths have contributed to this success and continue to do today.
Traditionally nurses delivered clinical information about the patient, the clinical events on their shift and the plan of care to the oncoming shift to ensure continuity of care and to make sure that their colleagues were informed about tasks or instructions that needed to be completed by the next shift. This process had a variety of names; report, handover or handoff. The format was often different from unit to unit. It usually took place in an off stage room or office or at a charting station from away from the
A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began
is to protect the health, safety and wellbeing of the public and their healthcare needs.
I shared this information with the night staff, left contact numbers and names and the Nurse was called the following morning.
Based on the information below, Elite Foam, Inc. will need to be set up in Made2Manage under a new vendor number. The current vendor number of 4018 is actively being used by Elite Comfort Solutions, LLC. and should continue reflecting the Newnan remit to address.
I still remember it as if it was yesterday, waking up with a throbbing left ankle that I had broken while snowboarding not 2 and half months earlier. Hobbling out the door in the snow as I went to the car, thinking that I should be on leave and enjoying the snow, but instead I was going to work. We were conducting a military deployment exercise, and I didn’t want to be at work. I was a gorgeous day outside; the sun was shining, no wind to speak of, and it was a breathtaking day. Nonetheless, there was an eerie calm, despite being in a mock deployment line all day.
On 10/16/2015 I spoke with Kalila Dowden, parent of Kaylee P. at the operation . Ms. Dowden had come to pick her daughter up while I was at operation for the inspection. I spoke with Ms. Dowden in the office. Ms. Dowden stated Shana Myers the teacher of Kaylee had contacted her and stated she believed Kaylee had a seizure on the playground and EMS had been called. Ms. Dowden stated she had told Ms. Myers she was on her way. Ms. Myers stated shortly after arriving at the center EMS had shown up and she had refused care as she believed her daughter did not need to go to the hospital. Ms. Dowden did state she did not take her daughter to the doctor or hospital as her Neurologist is in Dallas and Ms. Dowden states she is aware of what she is suppose
With the evolution of healthcare, patient handovers have become not only a concern in Ontario, but an international concern. The handover (or handoff), also known as a critical transfer point, is the communication between units and healthcare teams that involves the transition of patient information. During a period of care, a patient can potentially be treated by multiple healthcare members in various clinical settings across the continuum of care. The handoff can occur between specialized outpatient, emergency, surgical, and intensive care units and include encounters with numerous staff members at each interval. Some nursing units transfer or discharge their patients at a rate of 40-70% everyday (Friesen, White & Byers, 2009). Consequently,
At 3 am while the aide had her sleep brake, the patient’s husband called her to help him patient back to because the patient fell out of the bed during her sleep. As per aide, there were no visible injuries and the patient and her husband refused to call 911. Patient‘s PCP notified and patient’s children as well. RN visits scheduled for post fall
and state the procedure he was having, I refused to proceed with the scheduled procedure. At the time, I was unable to reach family members as well. I communicated this to the rest of the O.R. team,
The post-partum section of the women’s department is dedicated mostly for women who have already given birth. Although they have a labor and delivery room set up just in case any surprise or emergency births occur. I was told in my orientation that this room is rarely used and if it does get used than the most of the nurses will be working with that mother in labor. When I came into the hospital to volunteer, I noticed that the room was occupied and the nurses were working on the laboring mother. Since I am not qualified to help out the nurses during this situation, I went to my post at the nurse’s station and watched the phone that is linked to the other patient rooms.