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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the Institute of Medicine in 1999 reported that “nearly a million patients each year are injured in hospitals in the United States due to error. Medication errors occur more often than other categories of preventable errors (19%)‚ and most medication errors occurred during medication administration (34%) where they were more likely to directly impact the patient and cause harm.” (Gooder‚ 2011). Not long after looking at these percentages was the BCMA (Barcode
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Athanasakis‚ E. (2012). Prevention of medication errors made by nurses in clinical practice. Health Science Journal‚ 6(4)‚ 773-783. Brady‚ A.‚ Malone‚ A.‚ & Fleming‚ S. (2009). A literature review of the individual and systems factors that contribute to medication errors in nursing practice. Journal Of Nursing Management‚ 17(6)‚ 679-697. doi:10.1111/j.1365-2834.2009.00995.x Choo‚ J.‚ Hutchinson‚ A.‚ & Bucknall‚ T. (2010). Nurses ’ role in medication safety. Journal Of Nursing Management‚ 18(7)‚ 853-861.
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Root cause analysis (RCA) is a structured method used to analyze serious adverse events. The goal of RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals. A team focuses on the identification of the errors that occurred. They analyze each error to determine the underlying factors (root causes)‚ than if eliminated‚ can reduce the risk of similar errors in the future. Next‚ they put a plan into place‚ this will
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RUNNING HEAD: RTT1 TASK 2 1 RTT1 Task 2: Root Cause Analysis‚ Change Theory‚ FMEA‚ and Nursing Western Governors University RTT1 TASK 2 2 RTT1 Task 2: Root Cause Analysis‚ Change Theory‚ FMEA‚ and Nursing Root Cause Analysis (RCA) A root cause analysis (RCA) is an essential tool that can be used to examine and understand the ways in which systems fail as well as discuss those specific failures that led to a specific adverse event and potentially implement steps or behaviors to
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professional field of experience. EDUCATION HISTORY: ➢ 2010-recently enrolled Master of Arts in Nursing (Clinical Supervision) University of San Carlos‚ Cebu City ➢ 2004 to 2006= Master of Arts in Nursing (Nursing Administration) Completed the 33 units and passed the Comprehensive examination Pamantasan ng Lungsod ng Maynila ➢ 1990-1994= Bachelor of Science in Nursing University of Perpetual Help System of Laguna Dean’s List from 1st year to 2nd year
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investigation is to determine the root cause analysis (RCA) of the sentinel event‚ which occurred in the emergency room. Once the cause is identified‚ a plan of action will be established‚ and a failure mode and effects analysis (FMEA) will be done to reduce the likelihood that the new processes
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which occurred at Nightingale Community Hospital and analyze all aspects of the event. This analysis includes a review of the personnel present‚ barriers to the personnel being able to adequately complete their job‚ and how future staff interactions may be improved. In addition‚ the analysis will review the selected quality improvement approach to be used during the completion of a root cause analysis of the event and what can be done by Nightingale Community Hospital to ensure the sentinel event
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CIN: Computers‚ Informatics‚ Nursing & Vol. 32‚ No. 12‚ 589–595 & Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins F E A T U R E A R T I C L E Impact of an Electronic Medication Administration Record on Medication Administration Efficiency and Errors JEFFERY MCCOMAS‚ MSN‚ RN‚ CNS MICHELLE RIINGEN‚ DNP‚ RN‚ CNS-BC SON CHAE KIM‚ PhD‚ RN Congress authorized an initiative in 2004 to create a national health information technology infrastructure to improve patient outcomes through
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in the United States from medication errors. It is the fourth leading cause of death in the United States. According to the National Counsel for medication error Reporting and prevention defines medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medications in the control of the health professional‚ patient or consumers. Medication errors are surprising common and costly in all nation. Medications administration is a complex
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