... as outlined on the root cause analysis matrix for the specific type of event. An area on the matrix that may not have an identified process breakdown should still be summarized to determine that the component was evaluated. Brief description of event Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death, loss of function). A 3-‐year-‐old female pediatric patient who was under went her pre-‐operative assessment as an outpatient at her Ear, Nose and Throat (ENT) surgeon’s office. On the day of surgery, the patient and her custodial parent, the mother, presented to the ambulatory surgery center...
Words: 3407 - Pages: 14
...Sentinel Event: Sentinel events are a subset of medical adverse events. Events that require immediate attention are called Sentinel Events. Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Sentinel Event identified by Joint Commission also include infant abduction or discharge to the wrong family. Summary of the Sentinel event in the Case Study: Sentinel event presented in the case study involves discharge of a minor to the wrong family. Joint Commission requires immediate attention to such matters so that it may be avoided in the future. The summary of the event is that a 13 year old teenager, Tina, was admitted for day surgery. Tina was accompanied by her mother. After dropping Tina for the surgery at the hospital, her mother left to run some errands. Before leaving, she left her contact phone number with the pre-op nurse. After the surgery, Tina was inappropriately released to her father when her mother was delayed in returning to pick-up the daughter from the hospital. The hospital staff had no awareness of the family situation. Upon arrival at the hospital after the errands, mother was informed that Tina’s father had picked up Tina from the hospital because...
Words: 7455 - Pages: 30
...Business Communication Trends Paper Axia College of University of Phoenix Instructor: Pediatrics Associates is a doctor’s offices that treats children from the ages of newborn to 17 years of age. We have to have communication skills that are effective to compete with other offices in their area and to keep the doctor’s office profitable. Our day-to-day activities require communication and effective forms of communication for example: scheduling appointments, our phone staff must be able to have good listening skills, good spelling, and be able to determine what the parent is calling for and know medical terminology. In addition, somewhat be able to asset what could be wrong with patient and in some case determine whether the parent should bring the child into the office or go straight to the emergency room. Our phone staff also has to use those same communication skills to cancel appointments and the communication between parent and Medical Assistant (MA) is vital to be able to relay a problem list of what is wrong with the patient and what their visit is for to the doctor. Whatever information is gathered by the MA has to be accurate, because the information that is given to the doctor helps in the diagnosis of the patient. The doctor then must then tell the MA what form of treatment to perform on the patient. The technologies we use in our office on day-to-day basis to make the day flow proficiently are as follows: a paging system that anyone can hear from anywhere...
Words: 800 - Pages: 4
...of several health professionals to maximize the efficiency of both the clinicians and the health care system” (Slippery Rock University, 2007). In other words, it is the intermingling of multiple healthcare disciplines in order to provide the best patient care. An example of this could be the work on a surgical floor where nurses, physicians, surgeons, physical therapy, respiratory therapy, social work, and home health all work together to ensure that each aspect of the recovery is managed well. The clinical case to be discussed is a two month old male who arrived in the pediatric emergency room after a referral from the pediatrician’s office. The child presented to the pediatrician with a two day history of coughing, runny nose, decreased intake and a fever. The child had very few wet diapers in the past 12 hours. The child showed signs of dehydration and was sent by helicopter with the pediatric transport team to the regional children’s hospital. Upon arrival to the emergency room the child had increased work of breathing and was intubated due to impending respiratory failure. The child was fluid resuscitated and lab and chest films were obtained. Once stabilized, the patient was transferred to the pediatric intensive care unit. Once the parents arrived, social...
Words: 1114 - Pages: 5
... 1982 – 1985 Diploma in Nursing Bryn Mawr School of Nursing 130 S. Bryn Mawr Avenue Bryn Mawr, PA 19010 1980 – 1982 Associates Degree – Nursing Lebanon Valley College 101 N. College Avenue Annville, PA 17003-1400 Licenses DE Registered Professional Nurse (multi-state) L1 – 0036388 PA Registered Professional Nurse RN – 276374L Certifications 2011 – Present Certified Pediatric Emergency Cert # CP0060799 Nurse 2008 – Present Certified Pediatric Nurse...
Words: 1133 - Pages: 5
...Sentinel Event 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 mother were taken to the pre-op area for the preparation for the surgery. After completion of pre-op screening but prior to the patient entering the operating area, the mother stated that she was leaving campus to address a personal matter involving her other child while the patient was in surgery. Contact information was obtained from the mother prior to her leaving the hospital grounds. After this discussion, the patient proceeded to the operating room. After a successful and uneventful surgery, the patient was taken to the Post Anesthesia Care Unit (PACU) for recovery. At this time, the mother was paged overhead to the PACU, but was found to have not yet returned to the hospital. The recovery process was completed and the patient was transferred to the post-op discharge unit pending pickup. The patient was at this time exhibiting anxiety and was distraught from not having a parent present. Another attempt was made to contact the mother by paging her overhead to the discharge unit...
Words: 3209 - Pages: 13
...Reducing Risks of Child Abductions at Nightingale Community Hospital A sentinel event in the hospital is an unexpected occurrence that involves or poses a high risk for death, serious physical injury or severe psychological damage (Joint Commission, 2013). Incidences that lead to adverse outcomes necessitate immediate attention and plans of actions to prevent recurrences. The Joint Commission, a non-profit certifying body for healthcare organizations, sets safety and quality standards for hospitals. It requires hospitals to conduct root cause analyses (RCA), implement processes to reduce risks of recurrence and evaluate the effectiveness of those processes for sentinel events (Joint Commission, 2013). Nightingale Community Hospital (NCH) had a child abduction sentinel event. The legal guardianship of a child who had surgery was not communicated to various departments of the hospital. The parents of the child were divorced and the mother had legal custody. The child was discharged home with her father. Fortunately, law enforcement located the child at her father’s home and no charges were filed. National statistics show that 9% of missing children are abducted by family members and 3% are kidnapped by non-family members (Polly Klass Foundation, n.d.). Less than 1% of abducted children are victims of homicide, physical abuse and/or sexual assault (Polly Klass Foundation, n.d.). Although these percentages are very low, the impact is great! This means a child who is abducted...
Words: 3713 - Pages: 15
...Collaborative Communication: Integrating SBAR to Improve Quality/Patient Safety Outcomes Cynthia D. Beckett, Gayle Kipnis Purpose/Evidence-Based Practice Question Collaborative communication and teamwork are essential elements for quality care and patient safety. Adverse patient occurrences are an extremely common outcome of communication failures (Leonard, Graham, & Bonacum, 2004). In 2004, the Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) analyzed 2,455 sentinel events from hospitals across the United States and reported through root cause analysis over 70% of the events were due to communication failures, and approximately 75% of the patients involved died (Leonard et al., 2004). Although improving communication has been included as a Joint Commission’s National Patient Safety Goal for hospitals since 2003, in 2006, handoff communications were included as a specific communication subset. NPSG 02.05.01 states ‘‘The organization implements a standardized approach to handoff communications, including an opportunity to ask and respond to questions’’ (Joint Commission, 2006). Michael Leonard, MD, from Kaiser Permanente- Denver introduced a collaborative communication tool to support patient safety and outcomes. The structured communication tool is Situation, Background, Assessment, and Recommendation (SBAR) (Haig, Sutton, & Whittington, 2006). The SBAR tool provides a framework for organizing information...
Words: 5750 - Pages: 23
...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 contact her if the procedure was finished earlier than planned. Upon completion of surgery and recovery, the patient’s mother was paged from the waiting area by the recovery nurse. The mother was had not returned to the hospital at this time. The patient care was then transferred to the discharge nurse while waiting for the mother to return. During this time the patient was very upset and crying for her mother. The discharge nurse was notified that the father was in the waiting area and approved for the father to see the patient. The father was with the patient for about 30 minutes and the mother had still not arrived. At that time, with no specific information about the patient’s custody arrangement, the discharge nurse provided the father with discharge instructions and allowed him to leave with the patient. When the mother arrived to pick up the patient, she was very upset that the patient was released with the father who does not have custody over the...
Words: 2598 - Pages: 11
...errors are a major problem in the healthcare community, and especially in pediatrics. “Up to 27% of all pediatric medication orders result in a medication error.” Keiffer, Marcum, Harrison, Teske, and Simsic (2014). There is far less room for error with drug administration when working with pediatrics. It should be a primary goal to significantly reduce the cases of medication error in ever facility. I will discuss the importance of reducing medical errors relating to a Pediatric Cardiothoracic Intensive Care Unit. The article titled Reduction of Medication Errors in a Pediatric Cardiothoracic Intensive Care Unit discusses the rate of medication errors in their unit, and the steps that were taken to try to eliminate or reduce the number of medication errors. “A medication error is defined as an error that occurs with the prescribing, dispensing, administering, adherence, or monitoring of a drug regardless of whether it results in patient harm or has the potential to result in patient harm.” Keiffer et al. (2014). The authors note that medication errors occur more often with administration issues as opposed to prescribing, ordering dispensing, or monitoring. The article discusses the health care professionals’ courses of action taken to reduce medication errors for their patients. The medical team implemented interventions and methods including: a double check system, hands free communication, a safety systems checklist, a distraction-free zone, information huddles...
Words: 323 - Pages: 2
...ALARA Concept for Performing Pediatric Head Computed Tomography With the advancement in Computed Tomography (CT) imaging technology and image acquisition is the importance of patient safety, particularly in pediatric imaging. CT has become one of the most popular diagnostic tools used in the clinical environment. In some facilities, CT scans constitute as much as 67% of the patient's annual exposures to ionizing radiation (Furlow, 2012). Physicians and technologists alike must be knowledgeable on how to perform the ALARA principle on their patients in order to deliver the least amount of radiation dose possible while achieving diagnostic quality images. Image Gently Campaign Image Gently and the Alliance for Radiation Safety in Pediatric Imaging has launched a campaign to increase the awareness of the importance of applying the ALARA principles when imaging pediatric patients with Computed Tomography. The Image Gently web site is a source of valuable information for parents of pediatric patients, physicians, technologists, and radiologists. The web site offers pediatric protocols as well as tracking mechanisms for parents of pediatric patients to keep track of their child's dose from clinical CT examinations. The web site offers educational resources for technologists through on-line presentations for continuing education in pediatric CT scanning describing techniques that technologists can employ to reduce dose to their pediatric patients. An example of one of the...
Words: 2530 - Pages: 11
...excellent, and compassionate healthcare provides for their patients’ needs. There values statement pledge to themselves and the community, is a commitment to four core values the first being Safety with the quote “We put our patients first”. A1 Sentinel Event As defined by the Joint Commission (2014) a sentinel event is an unexpected occurrence involving death, or serious physical, psychological injury, or the risk thereof. With this said Nightingale community Hospital recently experienced a sentinel event involving the possible abduction of a pediatric patient. As per reported, September 29th a three year old patient come to the hospital for a surgical procedures, accompanied by her mother. During the registration portion of the process the mother completed all the registration paperwork that was required. Along with authorization document, the patient was then directed to the pre-op area where the pre-op assessment was completed. It was at this time the mother informed the per-op nurse that she had several errands she needed to run while her daughter was in surgery, but she would be back to pick her up. The mother asked that if she had not return by the time her daughter surgery was completed to please call her mobile phone, and gave the pre-op nurse her numbers so it could be attacked to the chart. The mother was informed of how long the procedure generally takes, after that per-op was completed the patient was then taken over to the operating room (OR). It was at this...
Words: 2527 - Pages: 11
...Community Hospital’s value statements addresses safety. A key aspect in providing safe patient care includes communication among caregivers. A1. Sentinel Event Nightingale Community Hospital recently experienced a sentinel event that involved the possible abduction of a 3 year old patient. As defined by the Joint Commission (2014), a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. On September 14th a 3 year old patient came to the hospital for an outpatient procedure. She was accompanied by her mother. They first registered for the procedure and completed all required registration documents including authorization forms. The patient then went to the pre-op area to complete all pre-op assessments. At this time the mother informed the pre-op nurse that she had to take care of a personal matter with her son while her daughter, the patient, was in surgery. The mother gave her contact information to the pre-op nurse who then recorded it in her personal notebook. From the pre-op area the patient was then taken to the operating room. Both nurses and surgeons are present during the procedure. After the surgery, the patient was taken to a Post Anesthesia Care Unit (PACU). It is also referred to as the Recovery Room. Upon arrival, the mother had not yet returned. Throughout the recovery the 3 year old patient was becoming more insecure and nervous because her mother was not present. The recovery...
Words: 2935 - Pages: 12
...for release had changed. Mother arrived approximately 2.5 hours later to pick up patient and found that her daughter had been released 30 minutes prior to her arrival. At that point security issued a “Code Pink” (hospital-wide child abduction alert) and local law enforcement was contacted as well. Upon interviewing the patient’s mother, she stated she has custody of the patient and siblings as the parents are currently divorced. Within 30 minutes of mother’s post-op arrival, local law enforcement confirmed the child was in care of her father. Furthermore, the father and child were located at father’s residence awaiting the arrival of the mother. The father was not charged of any crime. Furthermore, NMH CEO assured patient’s mother that the incident would be investigated and changes to policies may be implemented to prevent similar instances in the future. A2: Personnel Staff below in the order in which they made contact with the said sentinel event: Katie Jessup, Registrar: Ms. Jessup stated that she followed the proper check-in procedures and nothing more. She indicated that verifying the parent’s identity or the custody verification wasn’t a part of the in take process. Greta Doppke, Pre-Op Nurse: She stated that she prepped the patient for surgery and took the number down from the mother of the patient and was given instructions to notify the mother when the patient was...
Words: 2002 - Pages: 9
...also seeks to raise efficiencies and reduce costs for heightened care. One of the founders and president of the Children Health Fund is Dr. Irwin Redlener. “If you’re not part of the solution, your part of the problem.” In 1987 Children’s Health Fund Redlener co founded it with singer and song writer Paul Simon. The focus was on pediatric care for homeless kids. National network of Children’s Health Projects is delivered via doctors, nurses, and other professionals in a RV size mobile. The purpose of this is to drive to locations where people are in need of medical care. Places like city shelters, homeless families, and in 2009 the program expanded to deep urban areas. The clinics are supported by 41 mobile medical clinics: 32 medical, 3 mental health, 5 dental, 1public health, and 1 health educations operating in different programs across the country. Payments for medical care provided by Children’s Health Fund mainly come from four sources: private individual and corporate donation, congressional aid, and government health insurance programs that support children living in poverty. The Mobile Medical Clinics are design to provide pediatric primary...
Words: 865 - Pages: 4
