Kenney and Rick A. Honesty, emotion, compassion, and forgiveness are natural elements of our story, as are the fears of blame, liability, or bad public relations that generate reluctance to communicate after someone is hurt. By reaching across the chasm that opens between provider and patient when medical injury occurs, we were able to identify gaps in crucial trauma support services that had left each of us feeling terribly isolated for almost two years. Neither of us fully appreciated this obstacle to our being able to heal and get on with our lives until we talked about it with one another.
RA Porche Jr, ed. Joint Commission Resources; Medical errors have been present in healthcare since the beginning of time. Sincethe Joint Commission has gathered and reported data on the most serious types of errors; sentinel events. All nurses, in all healthcare settings, play a key role in the prevention of these errors.
Front Line of Defense offers all nurses from staff nurses to chief nursing officers a reference complete with tools to help prevent medical errors. This book begins with an overview of sentinel events including trends and statistics.
The book moves on to the most commonly identified root causes of Hospital sentinel event sentinel events describing the various ways a nurse can intervene and speak up to prevent errors and begin to effect a change in the culture of their work environment.
The remaining 10 chapters are each focused on a different type of sentinel event including operative and perioperative errors, medication errors, transfusion-related errors, falls, wrong-site surgery, restraint and seclusion, suicide, potential death and injury, and healthcare acquired infections.
Each chapter provides examples of sentinel events and the major root causes identified for those events. Practical strategies are offered for each of the identified root causes that nurses can use to prevent each type of error.
Each topic covered in the book is clearly presented and thoroughly discussed. The discussion of each type of sentinel event, reasons as to why the events is of concern and the identified root cause provides the reader with insight as to how the Joint Commission approaches the issue.
These insights are passed on to the reader with clear suggestions as to how nurses can intervene to prevent them from occurring.
Most of the strategies offered are practical; however, some will be more challenging to tackle than others. Nurses working in a healthy environment, with a leadership that is thoroughly committed to safe, high-quality care for their patients will find the strategies easier to implement than those working in organizations who have not completely embraced the required culture of safety.
The theme of teamwork and multidisciplinary approaches to error prevention is carried throughout the book. Front Line of Defense should be available to all nurses in their work-place. It is particularly helpful in providing a thorough examination of the various root causes that may not come to mind when reviewing errors.
This book can be used as a practical reference for anyone working with teams on error reduction, involved with policy and procedures, or with an interest in the prevention of sentinel events.Medical Errors, Adverse Events and Cost An April study compared voluntary reporting to the “global trigger tool” and concluded that the number of hospital adverse events is actually ten times what was previously believed.
and three private practices, for "sentinel" events involving wrong-site pain management procedures. A total. Type of Sentinel Event: (Check only one) Abuse, Neglect, Exploitation, Hospital/Nursing Facility/ICF Admit, Emergency Room Visit, Death, Involvement with Criminal Justice System.
sentinel event management model in an acute care hospital that is part of a healthcare system, based on best practices and principles of high reliability organizations. SENTINEL EVENT 8. The Sentinel Events Policy encourages accredited facilities to self-report certain "sentinel events" within five days of their occurrence.
A facility that fails to report a sentinel event risks being placed on Accreditation Watch, a publicly disclosable attribute of an organization's existing accreditation status. A sentinel event is defined as.
preliminary unusual incident - sentinel event report Complete all information when reporting Incidents/Events. Fax to Division Director’s Office 1-() . Assaults on staff at Western State Hospital costing millions Eleven patients have died at the facility since in circumstances deemed to be “sentinel events,” defined by federal.