Sentinel Event Case Study
A1. Sentinel Event:
Nightingale Community Hospital, a not-for-profit hospital, prides itself as a leader in high quality health services and envisions itself as the hospital of choice for patients, employees, physicians, volunteers, and the community. In order to achieve its mission of creating a healing environment with a passionate commitment to healthcare excellence, Nightingale Community Hospital takes the safety and well-being of all its patients seriously. The hospital board and senior management analyze and process all sentinel events in order to prevent them from recurring. On September 14th at 12:30PM, a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, occurred …show more content…
Complete time-out procedure prior to surgery. Assist the surgeon during surgery while maintaining a sterile field. Chart nursing notes. Give nursing report to recovery nurse during patient hand-off.
Recovery Nurse Take nursing report from OR nurse. Provide post-anesthesia care to the patient. Chart nursing notes. Locate patient’s parents/guardian in waiting room. Reunite parents/guardian/family with patient. Give nursing report to discharge nurse during patient hand-off.
Discharge Nurse Take nursing report from recovery nurse. Give discharge care instructions to patient/parents/guardian/family as appropriate. Discharge minor patient to parents/guardian. Discharge adult patients to family/caregivers. Chart nursing notes.
Surgeon Coordinate, communicate, and schedule patient care from his practice with the hospital ambulatory surgery unit. Perform surgical procedures in accordance with regulations.
Security Responsible for the security and safety of staff, visitors, patients, families, and volunteers of the hospital. Patrol the hospital grounds and areas for suspicious activity and persons. Notify and assist with the local law enforcement as needed for criminal offenses. Develop, review, modify, and implement hospital policies and procedures related to the safety and security of hospital …show more content…
This is important because hospital employees are valuable resources and not easily replaced. The employees are the front-line workers that provide the service and delivery the care to the patient, or hospital’s customers. These front-line employees need to be empowered to develop and implement the countermeasures to the barriers in their workflow (Lean Pathways, n.d.). The root cause analysis using Lean problem solving principles of this sentinel event identified the following: inadequate standard for patient hand-off, inadequate adherence to the standard for clinical documentation in the electronic medical record, and inadequate system to collect custodial rights
Nightingale Community Hospital, a not-for-profit hospital, prides itself as a leader in high quality health services and envisions itself as the hospital of choice for patients, employees, physicians, volunteers, and the community. In order to achieve its mission of creating a healing environment with a passionate commitment to healthcare excellence, Nightingale Community Hospital takes the safety and well-being of all its patients seriously. The hospital board and senior management analyze and process all sentinel events in order to prevent them from recurring. On September 14th at 12:30PM, a sentinel event, an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, occurred …show more content…
Complete time-out procedure prior to surgery. Assist the surgeon during surgery while maintaining a sterile field. Chart nursing notes. Give nursing report to recovery nurse during patient hand-off.
Recovery Nurse Take nursing report from OR nurse. Provide post-anesthesia care to the patient. Chart nursing notes. Locate patient’s parents/guardian in waiting room. Reunite parents/guardian/family with patient. Give nursing report to discharge nurse during patient hand-off.
Discharge Nurse Take nursing report from recovery nurse. Give discharge care instructions to patient/parents/guardian/family as appropriate. Discharge minor patient to parents/guardian. Discharge adult patients to family/caregivers. Chart nursing notes.
Surgeon Coordinate, communicate, and schedule patient care from his practice with the hospital ambulatory surgery unit. Perform surgical procedures in accordance with regulations.
Security Responsible for the security and safety of staff, visitors, patients, families, and volunteers of the hospital. Patrol the hospital grounds and areas for suspicious activity and persons. Notify and assist with the local law enforcement as needed for criminal offenses. Develop, review, modify, and implement hospital policies and procedures related to the safety and security of hospital …show more content…
This is important because hospital employees are valuable resources and not easily replaced. The employees are the front-line workers that provide the service and delivery the care to the patient, or hospital’s customers. These front-line employees need to be empowered to develop and implement the countermeasures to the barriers in their workflow (Lean Pathways, n.d.). The root cause analysis using Lean problem solving principles of this sentinel event identified the following: inadequate standard for patient hand-off, inadequate adherence to the standard for clinical documentation in the electronic medical record, and inadequate system to collect custodial rights