Question

Please provide proper citation with page numbers of the material you are referencing in your homework paper Homework assignment should be 1-2 pages, not including reference page, double-spaced. Review an article related to a sentinel perioperative event. Be sure to summarize the article. Include the following: 1. What is a sentinel event? 2. Give background information on the patient (i.e. age, past medical history, admitting diagnosis). 3. Discuss the cause of the sentinel event, if it resulted in any complications (ie. injury, trauma, death). 4. Discuss preventable measures related to this event i.e. raise side rails, review of 5 rights of medication administration, etc.). 5. What did you learn from the article?

subject: med. surge.

Answer 1

Unwanted events of serious disability or events even death of the patient in health care organizations not due to patients own disease should invite analysis of the event to minimize recurrence.

Joint Commission, describes the types of errors that have been reported in health care organizations. They also described how organizations can respond to these events, how sentinel events are investigated through   analysis, and the Joint Commission’s policy on sentinel events are clearly depicted in their publication "Sentinel Events: Evaluating Cause and Planning Improvement", Here many case studies of unwanted events and examples of successful investigation and improvement efforts in health care organizations were depicted

A sentinel event is also called a never event . This is so called because in healthcare it should never happen, e.g the patients death or serious complication or disability due to faulty procedure or medical errors and not due to patients illness .It was first told by Ken Feizer ,MD, CEO of National Quality Forum.

Adverse events such as wrong surgical procedure like surgery in the left leg instead of right leg, as the tumor was in right leg which should never occur.

Initial report was made in 2002 and after multiple revision it consists of 29 serious reportable events grouped into 7 categories.

1. surgerical or procedural events like surgery in wrong body part or wrong patients or wrong procedure ,unintentional retention of foreign objects inside the patient etc

2.Product or device event----patients death due to infected device, contaminated drugs or serious injury due to device, death due to iv air embolism while in healthcare setting etc