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.
What made this whole thing even worse was when he looked at my grandmother and just said “where is the baby”? That took a few days to figure out but at the time he was ill my wife was pregnant with our little girl. When we finally realized he kept asking about our baby he kept smiling upon talking about her. Our little girl was born a day earlier than her due date in November. After we were able to leave the hospital we went straight over to my grandfather’s house to show him that the baby was here.
BIS 155 Lab 6 of 7: Day Care Center Purchase here http://chosecourses.com/BIS%20155/bis-155-lab-6-of-7-day-care-center Product Description Your friend, Jane Morales, is considering opening a Day Care Center. She has started compiling her assumptions and putting together an Income Statement. She has determined that she must make at least $75,000 profit per year in order to start the business. She has asked you to analyze her Income Statement and help her determine whether it is viable for her to start this business. You have agreed to help her complete her Income Statement and to perform What-If analysis to help her look at her potential profitability.
“Ordeal By Cheque” By: Julia Baer There once was this lady named Meredith, and she was around 24 years old. She was 12 months pregnant. She also had a husband named Brad that was around the same age as her. One day they decided they needed to start buying baby products for their infant coming in a few weeks. They spent a good amount in the store but it was just because they weren’t prepared.
Later see knew that her mother’s birthday was coming up and her grandparents were coming to get her for a road trip. They were going to go to Lewiston, Idaho, and on the way her Gram asked her to tell them a story. She thought it was real weird because all the stories she knew were the ones that her Gram and Gramps told her, but she thought she could
What inspired me the most from the Drink and Drive presentation was when Sarah Gino started sharing her story. My first impression of Sarah Gino was the obvious, “she is young, beautiful, and she is blind.” But when she started talking about her story it really had me putting things into prospective. After Sarah was helped onto stage by her Dad, she started talking about an accident that involved her. She mentioned nine years ago, on a nice January day, she and her EX decided to ask his Dad to borrow his car in other for them to go to his cottage. Her ex’s Dad said “ OK” on that note, she decided to invite her sister and her sister’s boyfriend to the cottage as well.
Diana’s sister was to be married less than a week after the conference and upon her query to Diana if she would be able to attend Diana replied, “My life isn’t my own, I don’t make the decisions about how I use my time.” Despite Diana’s own admittance of loss of control over her own life, her family held strong that they would see her return. And they did, albeit briefly, when Diana returned home for Christmas that year, however that would be the last time her family would see her alive. Three months later Diana’s death would mark the beginning of the end of the Weathermen. The life and death of Diana Oughton is portrayed as one of victim, martyr, and radical in Diana: the making of a terrorist but one can be certain that although each argument can be made, Diana’s life was much more complex than the sum of it’s parts. Powers’ book is of great importance in understanding the various relationships in Diana’s life and how they affected her time on earth but one is left wondering exactly who Diana was and what she could have accomplished had she chosen a different
Addie’s daughter, Dewey Dell, has recently become pregnant because she fooled around with a farmhand (Lafe). Addie made Anse vow that she would be buried in Jefferson; even though her desire was much more troublesome than burying her at home, Anse did as she wished. On the first night, there was a flood so
Military After High School I had just completed three years of high school in the summer of 1982. This was my senior summer. I planned my whole summer during the winter months. My mother purchased a motorcycle for me that Christmas. I rode a lot during the winter.
Or, rather, it did have, but “Our mother died when I was two,” says Scout, “so I never felt her Absence”. (Charles J. Shields 42) Moving out of Monroeville, Harper attended Huntington College for Women. After one year she’d had all of the proper etiquette she could take and moved to the the University of Alabama, where she became the editor of the “politically satirical student newspaper”(George Marotous). Harper’s father and sister, Alice, were lawyers, and with her drive for civil rights, she tried to follow suit, but dropped out 6 months before graduation. Numerous unrewarding jobs kept her writing confined to weekends until a friend who believed in her work leant her the money to be able to write full time.