Risk Management And Sentinel Events - 1322 Words

Portfolio Project: Risk Management and Sentinel Events According to the Joint Commission (2014), a sentinel event is an unexpected occurrence whereby a death or serious physical or psychological injury occurs. Because of their severity, there is an expectation of an immediate investigation and response to the event. In the case study (2014) for analysis, a serious sentinel event occurred with the death of an infant born to a mother with a history of syphilis. While understandably upsetting, a sentinel event can also have long-term, deleterious repercussions for a healthcare organization. The following analysis will detail the event itself, but will concentrate on the risk manager’s role in investigating, addressing, and responding to this or any sentinel event. In addition, the discussion includes the importance of initializing preventative measures to mitigate the risk of future recurrences. While avoiding risk is everyone’s business, the risk manager’s role is vital to protect against losses, litigation, accreditat ion issues, and damage to the organization’s reputation in today’s complex healthcare environment. The Sentinel Event and Risk Management Every day in this country, millions of people enter the hospital for a variety of reasons with the expectation of receiving the best of care. In the vast majority of hospital admits, the patient is treated and discharged without incidence. However, this is not the case for the estimated 210,000-400,000 annual patient deathsShow MoreRelatedRisk Management Plays a Vital Role in Healthcare Organizations606 Words   |  3 Pages Risk managers are a vital lifeline in the healthcare organization. If this organization had an active risk manager in place, many of the events leading up to the infant losing its life could have been prevented. There are many steps that a risk manager must take once a risk is identified, this paper will walk through the steps that are required after the risk happened. A risk manager plays an important role with the events in this infant case study. Risk managers hold a wide varietyRead MoreRisk Management Helps to Prevent Errors Essay1229 Words   |  5 Pages Ways that the risk manager could prevent this type of event happening in the future would be to establish and maintain a functional pediatric formulary system with policies for drug evaluation, selection and therapeutic use. To prevent timing errors in medication administration, standardize how days are counted in all protocols by deciding upon a protocol start date. Limit the number of concentrations and dose strengths of high alert medications to the minimum needed to provide safeRead MoreDescription And Scope Of The Problem1659 Words   |  7 Pages2014; Lukasewicz Anderson, 2015). The Joint Commission (TJC) issued a Sentinel Event Alert in 2013 on device alarm safety which subsequently led to the creation of the National Patient Safety Goal 06.01.01 (TJC, 2014). Th e alert and goal was published with an aim at acute care hospitals because of reported adverse and sentinel patient events and data that related to the nature of these events, indicating there is significant risk related to clinical alarm systems. The NPSG 06.01.01 is a requirementRead MoreThe Effects Of Risk Management On Health Care Organizations894 Words   |  4 PagesIn the context of risk management, there are several ways that Failure Mode and Effects Analysis can be used to improve processes in health care organizations. According to Stanley Davis and colleagues, documenting and analyzing potential risks proactively is essential for improving patient safety (Davis, et al., n.d.). The article states that Failure Mode and Effects Analysis (FMEA) is used prospectively to identify the possible system failures, and to fix the problems to make the system more robustRead MoreEssay on Providing Quality Patient Care1513 Words   |  7 Pageshealthcare that considers individual ne eds, preferences, and culture. (5) Equitable: healthcare quality that does not vary because of race, gender, ethnicity, geographical location, or socioeconomically status. (6) Safe: healthcare that minimizes harm and risks to patients. (Bengoa, 2006) Another factor being looked at in quality of care is patient satisfaction. There has been some debate as to whether the patient’s perception of their care truly reflects the quality of care. I feel like this can be lookedRead MoreQuality Improvement And Risk Management1381 Words   |  6 Pagesdeveloped this manual to introduce new employees to the basic concepts of risk and quality management within the institution. This manual meets the institution’s initiative for continuous quality improvement within each department and the opportunity to mitigate areas of risk whenever possible. In order to accomplish this goal, it is important for the new employee to be able to identify what quality improvement and risk management mean within the institution. The institution believes that when employeesRead MoreThe Quality Risk Management Plan1331 Words   |  6 PagesThe quality risk management plan for this case study scenario includes identifying areas of risk and healthca re errors, in order to protect future patients from having their safety compromised. The case study describes two patients who received wrong-site surgery; which is considered a sentinel event – preventable and should never occur. According to a report by the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (2015) titled Wrong-Site, Wrong-Procedure, and Wrong-PatientRead MoreThe American Nurse Association ( Ana ) Code Of Ethics1263 Words   |  6 Pagesare known for their commitment in improving or increasing client health. However, this ethical commitment may not always be met due to breakdowns in healthcare delivery. Deviations such as adoption of unsafe practices or behaviors can lead to sentinel events. Any disconnects or disruptions can be a detriment to client care. This paper will present recent cases of witnessed breakdowns of facility protocols that have led to adoptions of unsafe nursing practices, discuss its impact to healthcare, andRe ad MorePatient Safety And The Medical Errors781 Words   |  4 Pagestoday’s fast paced healthcare environment, patient safety as well as healthcare quality has become a major priority. A growing focus on patient safety and the increasing medical errors has made various healthcare management teams more proactive in identifying and preventing potential risks for patients. While a great deal of progress has been made in recognizing most medical errors, it is also important to note that in a healthcare environment there are a number of factors involved, therefore the strategiesRead MoreRoot Cause Analysis of the Sentinel Event: The Child Abduction Case1675 Words   |  7 PagesRoot Cause Analysis of the Sentinel Event Abstract This paper highlights a root cause analysis of the sentinel event in a case involving child abduction. It describes the sentinel event in addition to explaining the roles of personnel present during the event. The paper further analyses the obstacles that may slow down efficient relations among the personnel present during the sentinel event. It discusses quality improvement methods used in the root cause analysis by outlining a corrective action