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Running head: ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP-RTT1-TASK 2

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Organizational Systems & Quality Leadership RTT1 – Task 2 Sue Stallings Western Governors University

Running head: ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP-RTT1-TASK 2

2

Sentinel events are those events that are supposed to never occur, or never events. A sentinel event, as defined by The Joint Commission, is an unexpected occurrence involving death or serious physical or psychological injury, or “the risk thereof”. (Sentinel Event: Joint Commission). During the course of our scenario patient’s admission, treatment, and recovery, he suffered such an event. Multiple contributory events culminated to bring our patient, Mr. B, to an unanticipated and tragic end. The response and duty of the organization is to collect data of all events contributing to the death of Mr. B. This data is analyzed, cause and effect identified, recommendations made, and protocols to improve the process of care like that of Mr. B are put into place. Successively, the evaluation process will determine the effectiveness of the changes that were made to ensure this type of event is further preventable. The methods used for this process are referred to as Root Cause Analysis (RCA) and Failure Mode Effects Analysis (FMEA). Additionally, hazards and errors are identified and categorized. Questions are asked as to whether the tasks and/or situations were independently a risk or a mistake. And, what are the key roles of nurses in quality healthcare and preventable inaccuracy. The issues outlined in the scenario will be used to formulate a RCA to determine cause, and to work through a FMEA to make recommendations for prevention in similar scenarios. Scenario: Mr. B is admitted to the ED for apparent dislocation left hip. There are additional patients are in various stages of discharge and assessment. A doctor and two nurses, one RN and

Running head: ORGANIZATIONAL SYSTEMS & QUALITY LEADERSHIP-RTT1-TASK 2...

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  • on April 3, 2014
  • Category: Miscellaneous
  • Length: 6,079 words
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