NRSG 314 Unit 4 – Discussion Board SOLUTION
Responses to Other Students: Respond to at least 2 of your fellow classmates with at least a 100-word reply about their Primary Task Response regarding items you found to be compelling and enlightening. To help you with your discussion, please consider the following questions:
- What did you learn from your classmate’s posting?
- What additional questions do you have after reading the posting?
- What clarification do you need regarding the posting?
- What differences or similarities do you see between your posting and other classmates’ postings?
According to The Joint Commission, a sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm and intervention required to sustain life (The Joint Commission, 2022). Accredited health care organizations are not required but are strongly encouraged to report sentinel events to The Joint Commission. If a sentinel event occurred, The Joint Commission is requesting the healthcare organization to prepare a comprehensive analysis the root cause of the event, and a corrective action plan.
As an employee working at a Kaiser Permanente urgent care department, I have learned that Kaiser promoted the culture of reporting medical errors in a blame-free environment with the intent to identify flaws in the system, to identify the root or systemic cause of error and to find strategies to create a safer patient environment by implementing interventions to reduce the likelihood of similar events occurring in the future. Similar to the Joint Commission, Kaiser promotes transparency by encouraging staff to report medical errors without blaming or finger-pointing. In addition, Kaiser has policies and procedures in place to provide internal quality control measures. According to the article “Kaiser Permanente’s Response to JCAHO’s Sentinel Event Standards: Our Significant Event Root-Cause Analysis Program Leads to Preventing Medical Errors”, Stajer and Pate write: “Quality and risk management committees routinely examine unexpected deaths and errors and monitor patient issues” and “Root-cause analysis with in-depth analysis done to identify the root or ultimate systematic cause of errors” (Stajer & Pate, 2000).
Policies and procedures set by the Joint Commission and other regulating agencies are important as their purpose is to protect the patients, improve the system and prevent further harm. It is one the means to improve patient safety and prevent future adverse events as well. By encouraging healthcare organizations to report sentinel events and provide a comprehensive analysis of the root cause of the event and a corrective action plan, healthcare organizations can help to prevent recurrence of similar events to prevent harm and danger to patients. Without policies, procedures and regulations, healthcare organizations may not report all sentinel or adverse events. As Sherwood and Barnsteiner stated, unreported events will not improve patient safety as we cannot learn from the events and therefore would now know how to prevent future adverse events and to improve patient safety (Sherwood & Barnsteiner, 2021).
Sentinel event policy and procedures. (2022). The Joint Commission. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-policy-and-procedures/
Sherwood, G., & Barnsteiner, J. (2021). Quality and Safety in Nursing (3rd Edition). Wiley Global Research (STMS). https://coloradotech.vitalsource.com/books/9781119684459
Stajer, R., Pate, B. (2000, June 1). Kaiser Permanent’s response to JCAHO’s sentinel event standards: our significant event root-cause analysis program leads to preventing medical errors. The Permanente Journal, 4(2), 117-123. https://doi.org/10.7812/TPP/00.962
Sentinel events are reported through Unusual Occurrence Reports (UOR) at the facility I work in. There is a process that is followed. When an event occurs that causes injury or can cause injury it is submitted to a database that is tracked region wide. An investigation is then started. This is where a root cause analysis is implemented. The people involved are interviewed in a blame free environment. The focus is on the why the mistake happened not who made the mistake. It is reported to JCAHO and this is when steps to figure out how to improve or prevent the problem will begin. There will be a plan on how the problem will be resolved and an action which is usually education of staff. Our facility follows the Joint Commission’s regulations regarding Sentinel event reporting. The goal is to find a way to improve and keep patient’s safe (Reijmerink, 2022).
It is important for the Joint Commission or other regulating agencies to provide policies and procedures in order to hold the facilities accountable on providing safe medical care with the focus on patient safety. When the facilities are accredited, they have a responsibility to provide quality, safe and continue to improve healthcare. They ensure a quality improvement process is provided and this process has to be data driven in order for results to be of quality. This ensures the public that the organization will meet and exceed high standards of care for the patients (Pullen, 2022).
Pullen, Richard L. Jr. EdD, MSN, RN, CMSRN, CNE-cl, ANEF. The importance of accreditation. Nursing Made Incredibly Easy!: May/June 2022 – Volume 20 – Issue 3 – p 47-48. doi: 10.1097/01.NME.0000824636.94923.af
Reijmerink, I. M., Bos, K., Leistikow, I. P., Groeneweg, J., Cnossen, F., Dongelmans, D. A., & van der Laan, M. J. (2022). Performance variability in perioperative sentinel events: report on a nationwide data set. British Journal of Surgery, znac067.