A 16-gauge IV catheter was inserted, and a lactated Ringer’s (LR) infusion was started. The triage nurse obtained the following history from the patient and his wife. C.W. has had idiopathic dilated cardiomyopathy (IDCM) for several years. The onset was insidious, but the cardiomyopathy is now severe, as evidenced by an ejection fraction (EF) of 13% found during a recent cardiac catheterization.
Running head: SENTINEL EVENT ROOT CAUSE ANALYSIS 1 Sentinel Event Root Cause Analysis Kalleen Campbell Accreditation Audit Task 2 April 20, 2013 SENTINEL EVENT ROOT CAUSE ANALYSIS 2 SENTINEL EVENT ROOT CAUSE ANALYSIS 1. Identification of Process This report was received regarding an event that requires investigation: The pre-op nurse told the mother that once Tina 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. The mother told the nurse that once Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number with instructions to contact her if Tina got out of surgery sooner than expected. Tina’s mother returned to pick her approximately 2 ½ hours later and found that Tina was discharged 30 minutes earlier.
She lived there along with cousins, and ended marrying David Lacks, known as Day. Henrietta’s sister Glady disapproved Day and Henrietta’s marriage. They had 5 children, Lawrence, Lucille, David, Deborah, and Joseph. Henrietta began getting severe pain so she went to Johns Hopkins, one the best hospital in the nation and had a colored ward. As she lay on the operating table, a sample of her cancerous cervical tissue was take without with her knowledge or consent and given to Dr. George Grey the head of the tissue research.
She start complaining to her mom about pain in her hip, next day took her to the hospital where they said she had symptom of a virus but days after the pain spread and the fever got worse. Addie been diagnosis with spread of MRSA, a staph bacteria that cause infections resistant to many antibiotics. Second case, David Ricci, 19 years old American face another threat in India. David been run over by a train and dragged underneath it. Lucky to be alive, he was rush to the hospital, where they cut of his leg.
Joanne Alexander was scheduled to have a surgical procedure at Orthopaedics of Indianapolis with Dr Kevin Scheid M.D. Patients over the age of 60 are required to have a chest x-ray done before any surgical procedures due to possible anesthesia issues. Mrs. Alexander, age 62 was x-rayed on the 24th of June; the Radiologist reading her x-ray report noted a “density” in the right upper lobe of her right lung reported and sent a hard copy of the report to Dr. Sheids office which was placed in her file apparently without notice of the radiology recommendation of comparison with previous x-rays. The plaintiffs maintain that they were not told of any problems or irregularities on the June 24th x-ray. 10 months later, in the spring of 1994 distressing symptoms brought Mrs. Alexander to a different doctor.
Sentinel Event The Joint Commission Nightingale Community Hospital experienced a sentinel event that involved the disappearance and possible abduction of a three-year old surgical patient. The 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.” (Joint Commission [JCAHO], 2013, p. SE-1) On September 14th, a three year-old patient presented to Nightingale Community Hospital for a routine outpatient surgical procedure. Tina’s mother completed initial paperwork with the hospital registrar.
A young mother is in intensive care after having a rare but serious reaction to a friend's prescription antibiotics that caused her to "burn" from the inside out. Yassmeen Castanada, 19, wasn't feeling well on Thanksgiving, so she took a pill that her friend had left over from a previous illness. Soon, Castanada's eyes, nose and throat began to burn, and she was rushed to the emergency room, her mother, Laura Corona, told ABC News. Her body erupted in blisters over the next few days, Corona said. She had to be sedated and placed on a ventilator.
The couple decide to go to a doctor and ask about a test-tube baby. Dr. Ziss, a very young man, tells them that Marie’s ovaries are shot, and that test-tube reproduction is impossible. Dr. Ziss questions the couple, he asks, "have they considered a surrogate mother?" [10] As he has already contacted a woman on their behalf, should they be interested. For ten thousand dollars plus hospital costs, they agree to have Wendy, a medical school student, as their surrogate mother.
Maternal risks of a multi-fetal pregnancy include hypertension, preeclampsia, gestational diabetes, and postpartum hemorrhage (Multifetal Pregnancy Reduction, 2013). Maternal and neonatal morbidity and mortality increase with each fetus. The most common method of fetal reduction is trans-abdominal multi-fetal pregnancy reduction. An ultrasound is used as a guide and a needle containing potassium chloride is inserted through the woman’s abdomen, into the uterus and into the fetal sac causing the heart to stop (www.webmd.com). Following the procedure, the fetal tissue is normally absorbed by the mother’s body.
Written Assignment #3: As Nature Made Him: The Boy Who Was Raised as a Girl As Nature Made Him is a phenomenal story about a medical tragedy and its traumatic outcome. After a botched circumcision, a family decides to raise their infant son, Bruce, as a girl. They rename the child Brenda and spend the next 14 years trying to transform him into a her. Brenda’s childhood dealt with much anxiety and loneliness. Her fear and confusion regarding her gender are present on almost every page of this book.