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.
It is claimed that Janet did not want to continue living her life if her illness could not be haulted. Dr. Raskind recieved a phone call from Dr. Kevorkian. During that phone call, Dr. Raskind tried to talk Dr. Kevorkian out of taking Janet Adkins on as a patient, telling Dr. Kevorkian that he believed Janet Adkins still had several years of life ahead of her, and stated that he believed Janet was still in very good spirits. It was also claimed that Dr. Raskind believed Janet Adkins was still getting full satisfaction from her life. Following the phone call from Dr. Kevorkian, Dr. Raskind made an attempt to call Janet Adkins, but was unsuccessful.
Nightingale Community Hospital Sentinel Event Analysis Sentinel Event A pediatric female patient was admitted for outpatient surgery by the mother. Once the patient went to the operating room, the mother left the facility to run and errand with the patient’s sibling and would return when the surgery was over. The mother left her cell phone number with the pre-op nurse to call if the surgery was over sooner than expected. The surgery was completed in 1 hour 45 minutes. When the patient was in the discharge unit the Discharge Nurse prepared the patient for discharge.
Friedman Family Assessment The H. family assessment was conducted with the Friedman Family Assessment. This assessment tool allows the nurse to complete the family assessment and intervene with the proper nursing diagnosis. The Friedman Family Assessment also allows the nurse to focus on “the health of individuals, families, and groups and the effect of their health status on the community as a whole” (Stanhope & Lancaster, 2012, p. 16). This paper will reflect on a family that consists of a grandmother, grandfather, and their grandson. Family Demographics The H family is an extended family consisting of grandparents raising their grandson.
Each state has a law called the Nurse Practice Act, and a governing body the State Board of Nursing. Nurses come into this profession with their morals and values that is part of what makes them individuals; this also comes into account as they handle varying situations at work. Case Studies Case study#1 is Marianne a 79-year-old woman who was admitted with a hemorrhagic stroke. She is unresponsive with dilated and nonreactive pupils, intubated on a ventilator, and without advance directives. Her husband and children have varying opinions on how to proceed with her care.
Meredith Case Study Leonida Shope Grand Canyon University: PCN: 529 September 17th, 2014 Meredith Case Study Meredith is a 24-year-old female who comes to the community counseling office where you work as a newly hired mental health counselor. On her intake form, which she filled out earlier while waiting for the appointment, she provides the following information, which is based on her answers to the questions on this form. Birthdate: 1/22/1980 Home: Whiting, MA Race: Caucasian Current job: Assistant to the activities director at a nursing home Parents: Married, both living, Leek, MA Father: Works full-time as a business manager Mother: Works part-time as an office clerk Parents’ histories: Father - heavy use of alcohol, two heart attacks; mother - use of prescription opiates for back pain. Siblings: Meghan, 22, who is employed full-time in the publishing industry in New York City; Molly, 20, engaged to be married, still in college; Sarah, 18 (Meredith reported during her first session that this sister is “acting weird, washing her hair constantly, scared to go outside, almost seems afraid of everyone and thinks everyone is talking about her - she refuses to go to high school”), and Brian,12, who lives at home. Medical history: Migraines?
It’s the patient’s responsibility to go to a doctor who has credibility and knows what they are doing. Patients should trust their physician and tell them everything and shouldn’t question what their physician is giving them. A patient should never contact their doctor during eating hours and sleeping hours. If for whatever reason, a patient doesn’t want to see their doctor anymore, the doctor should be given a reason why that is. And finally, one a patient has been treated they should acknowledge what has been done for them and always appreciate what their doctor has done.
Friedman Family Assessment Gwenevere Harris NUR/405 October 15, 2012 Michelle Hogsed Friedman Family Assessment The H. family assessment was conducted with the Friedman Family Assessment. This assessment tool allows the nurse to complete the family assessment and intervene with the proper nursing diagnosis. The Friedman Family Assessment also allows the nurse to focus on “the health of individuals, families, and groups and the effect of their health status on the community as a whole” (Stanhope & Lancaster, 2012, p. 16). This paper will reflect on a family that consists of a grandmother, grandfather, and their grandson. Family Demographics The H family is an extended family consisting of grandparents raising their grandson.
Patient Self-Determination Act HCR/210 October 5, 2011 Patient Self-Determination Act The Patient Self-Determination Act on health care delivery was effected because this gave the patients and their families the right to choose exactly how they wanted to have their medical care given. One example of this is the Do Not Resuscitate Order which is if a patient chooses not to let the medical staff restart their heart after it stops, then the medical staff would have to honor the patient's wishes and let them pass away. Without this order, the medical staff would have to do whatever means they have in order to save that patients life. This particular order is familiar to me because my mother in law signed a DNR Order because she was diagnosed with cancer and toward the end of her life, she was suffering and she chose to let her heart stop and end the suffering instead of having it restarted and suffer longer. This is a popular order because this gives the patients that suffer from a terminal illness, the ability to end their life instead of prolonging the pain.
If you become overwhelmed or severely stressed please confide in a friend, the Chaplin, or a medical health professional. Realizing that your children may not understand your spouse reactions or behavior attending family therapy is a must; this will provide a productive forum for the entire family to openly discuss any issues, fears, or emotions. It will also provide the family with an opportunity to ask the therapist for information about the PTSD and hopefully the therapist will answer in such a way that every member of the family can understand. Helping you’re spouse cope with the symptoms also requires that you continue to treat your spouse with the love and the respect he deserves (as a veteran willing fighting for his country) throughout the duration. Even if your family dynamics change avoid being judgmental, keep a positive attitude towards the coping strategies he learns in psychotherapy.