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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ROOT CAUSE ANALYSIS OF A SENTINEL EVENT Diane Swintek Western Governors University Root Cause Analysis of a Sentinel Event A root cause analysis (RCA) is a method by which we can examine a serious adverse event and identify the cause‚ or causes‚ that led up to the event. Although personnel are involved in these events‚ the primary purpose of the RCA is to identify the cause‚ not to assign blame (Agency for Healthcare Research and Quality‚ 2014). It is through identifying a cause‚ or
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Sentinel events are never something healthcare workers or facilities want to have occur. If an unfortunate event does take place‚ it is necessary to properly investigate the situation in hopes to learn from the event and hinder another episode. The following will discuss procedures used to investigate sentinel events such as root cause analysis‚ change theory and failure mode and effects analysis using the scenario involving Mr. B in Task 2 instructions. A. Root Cause Analysis Nursing
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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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A1. Sentinel Event Review of the medical record for the specified patient (SP) was completed 09/16/12. The medical record revealed that the SP was a minor child with a diagnosis of history of frequent and recurrent tonsillitis and was scheduled to have the tonsils and adenoids removed 09/14/12 at 10:30 AM as an outpatient procedure. Review of the medical record for the day of 09/14/12 revealed that the SP was admitted to the pre-admission testing area at 9:00 AM. At 10:00 AM the SP was in
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Running head: NIGHTINGALE COMMUNITY HOSPITAL SENTINEL EVENT Sentinel Event: Child Abduction Nightingale Community Hospital Greer Elizabeth Unruh Western Governors University 2 2 Communication is the be all and end all in a successful corporation. Nightingale Community Hospital was unfortunately lacking in this department when Tina‚ a child who was about to be discharged‚ was thought to have been abducted from the vicinity. The personnel in charge of Tina’s wellbeing at that time all gave
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NIGHTINGALE COMMUNITY HOSPITAL. RCA (ROOT CAUSE ANALYSIS) FOR THE SENTINEL EVENT REPORT HAPPENED ON MAY 14‚ THURSDAY AT 9:00 AM. 1. SENTINEL EVENT DESCRIPTION. The pre-op nurse told the mother that once Tina (The patient)‚ a 3 years old child‚ went to the OR‚ her surgery would take about 45 minutes and then she would go to recovery and she would be there at least one hour
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provide a logical description of a sentinel event 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
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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
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are the purposes of doing a RCA for an event such as this? Answer: The purposes of Root Cause Analysis (RCS) is to find out what happened‚ why such error did happen‚ and how to prevent it from happening again .The RCA process aimed to identify the root cause of the problem. It is a tool for identifying prevention strategies. Its effort is to build a culture of safety and move beyond the culture
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