Root Cause Analysis: Review of a Sentinel Event Western Governors University Root Cause Analysis: Review of a Sentinel Event Brief Description of the Event A 13 year-old girl‚ Tina‚ was admitted for outpatient surgery on September 14. Tina was accompanied by her mother‚ who was informed by nursing personnel she would be in surgery approximately 45 minutes and then recovery for one hour. Tina’s mother informed nursing personnel that she would be leaving‚ but would provide her cell phone number
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Can money buy all the happiness? Happiness is such a fact that fluctuates from one person to another. To some people money can simply be the most uncomplicated things in the world like bathing under the rain or a long drive. But to some people happiness is defined as their obsessions that only money can buy. These fascinations are things like branded cars‚ expensive jewelleries or luxurious visit to exotic places. But on the comparison both poverty and wealth can achieve ecstasy. When going around
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distorted in character or form‚ without restriction as to changes or alterations‚ in conjunction with my own or a fictitious name‚ or reproductions there of in color or otherwise‚ made through any medium at his studios or elsewhere‚ and in any and all media now or hereafter known for illustration‚ promotion‚ art‚ editorial‚ advertising‚ trade‚ publishing‚ or any other purpose whatsoever. I also consent to the use of any printed/video matter in connection therewith. I hereby waive any right that
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began in July 28‚ 1914 and had a duration of about four years‚ resulting in an end date of November 11‚ 1918. Although the atrocities began shortly after Archduke Franz Ferdinand was assassinated militarism‚ nationalism‚ and imperialism are the 3 root causes of World War I. Militarism is a mindset that a country’s government must possess an extensive army that is on the offensive and capable of vigorously defending oneself at any given moment. Militarism played such a huge role in beginning World War
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because her first son’s name is Kelvin. I was in the market buying generators and spare parts‚ when she called me. And I received her called I greeted her normally like I used to all of my customers‚ and she responded‚ there after‚ she complained bitterly‚ I can feel it from the tone of her a voice that she is not happy at all. The complain was that the 2.5kva automated voltage regulator(AVR) she bought from my shop is bad and the AVR had burnt her 2.5kva stator some call it feed coil. I couldn’t say
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Analysis of Sentinel Event: Child Abduction Root Cause Analysis (RCA): Child Abduction Please note the root cause analysis and recommended action plan show evidence of the key components of the RCA matrix for the specific 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 Tina‚ a 13 year old teenager admitted for day surgery‚ was inappropriately released to her
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Diagnostic Errors and Root Cause Analysis September 25‚ 2013 Table of Contents Introduction……………………………………………………………………3 Background…………………………………………………………………….3 Errors Identification…………………………………………………………....3 Cognitive Skills…………………………………………….4 Quality Measures......................................................................................................5 Patient-Centered Care……………………………………...6 Teamwork and Collaboration………………………………6 Evidence-Based Practice…………………………………
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No. Square. Cube. Sq. Root. CubeRoot. 1 1 1 1.0000000 1.000000 2 4 8 1.4142136 1.259921 3 9 27 1.7320508 1.442250 4 16 64 2.0000000 1.537401 5 25 125 2.2360680 1.709976 6 36 216 2.4494897 1.817121 7 49 343 2.6457513 1.912931 8 64 512 2.8284271 2.000300 9 81 729 3.0000000 2.080084 10 100 1000 3.1622777 2.154435 11 121 1331 3.3166243 2.223930 12 144 1728 3.4641016 2.239429 13 169 2197 3.6055513 2351335 14 196 2744 3.7416574 2.410142 15 225 3375 3.8729833 2.466212 16 256 4096 4. 0000000 2.519842 17
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Causes of World War 2 The root causes of World War 2 We can count many causes of World War 2‚ political and others‚ but the three root causes of World War 2 were : 1. The Prussian Militarism - developed in 200 years of history‚ it was the force that made Germany so powerful‚ and made it possible for a man like Adolf Hitler to gain total control of it. 2. Adolf Hitler - a madman and political genius‚ Adolf Hitler re-ignited the Prussian militarism after the German defeat in World War 1‚ and
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40 International Journal of Management Vol. 30 No. 1 March 2013 The Impact of Bank Board Composition‚ Top Management Equity Interest and Audit Committee Effectiveness on Top Management Transparency Udoayang Joseph Offiong University of Calabar‚ Nigeria Uket Eko Ewa Cross River University of Technology‚ Nigeria The aim of this study was to determine the impact of bank board composition‚ top management equity interest and audit committee effectiveness on top management transparency
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