Questions and Answers
What is the significance of Florence Nightingale's 'Notes on Hospitals' published in 1859?
What is the IOM's recommendation for patient care?
Evidence-based and individualized care based on patient needs and values.
A sentinel event can result in death or serious injury.
True
What is the main goal of the policies surrounding sentinel events?
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Sentinel events such as _____ and unintended retention of foreign bodies are commonly reported.
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Which of the following represents the most reported sentinel event in 2018?
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Organizations are required to report sentinel events to The Joint Commission.
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What does The Joint Commission require after a sentinel event occurs?
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Which of the following is NOT considered a sentinel event?
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What is the primary purpose of root cause analysis?
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Match the top root causes with their descriptions:
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Study Notes
Florence Nightingale
- Published "Notes on Hospitals" in 1859, establishing foundational nursing principles.
- Introduced the concept of "do no harm," emphasizing patient safety in healthcare settings.
Reducing Patient Harm
- Harm in healthcare arises from various sources; nurses historically adhered to the "Nightingale Pledge."
- The Institute of Medicine (IOM) advocates for evidence-based, individualized care tailored to patient needs and preferences.
- The Joint Commission focuses on Root Cause Analysis to evaluate sentinel events and implement corrective measures.
Sentinel Events
- Defined by The Joint Commission as unexpected occurrences that result in death or serious injury, including psychological harm.
- Serious injuries encompass loss of limb or major functions, with implications for potential risks needing immediate investigation.
Sentinel Events: Policy Goals
- Aim to enhance patient care and understand the underlying causes of sentinel events.
- Encourage changes in systems and processes to minimize future occurrences.
- Increase awareness and knowledge regarding sentinel events and their prevention to maintain public trust in the accreditation system.
Sentinel Events: Most Reported 2018
- Most frequently reported events include:
- Falls: 111 occurrences
- Unintended retention of foreign bodies: 111 occurrences
- Wrong-site surgeries: 94 occurrences
- Unassigned incidents: 68 occurrences
- Unanticipated events (e.g., asphyxiation, burns): 59 occurrences
- Suicide: 50 occurrences
- Delay in treatment: 43 occurrences
- Product/device events: 29 occurrences
- Criminal events: 28 occurrences
- Medication errors: 24 occurrences
Sentinel Events: Reporting
- Estimated that <2% of all sentinel events are reported to The Joint Commission.
- Reporting is encouraged but not mandatory for organizations.
Sentinel Events: Joint Commission
- A sentinel event is a patient safety incident that leads to death, permanent harm, severe temporary harm, or life-sustaining intervention.
- The Joint Commission mandates root-cause analysis post-sentinel event to identify contributing factors.
Sentinel Events: Not Reviewable
- Exclusions from review include:
- Near misses and events with full recovery.
- Medication errors without severe outcomes.
- Suicides outside 24/7 care environments or following discharge against medical advice.
- Minor harm occurrences lacking significant clinical implications.
Root Cause Analysis
- A methodology to pinpoint fundamental factors leading to performance variations and sentinel events.
- Emphasizes data evaluation and process audit to address underlying process deficiencies contributing to errors.
Top Root Causes
- Factors contributing to sentinel events include:
- Communication breakdowns
- Inadequate orientation/training
- Insufficient patient assessment
- Staffing issues
- Lack of accessible information
- Competency and credentialing concerns
- Noncompliance with established procedures
- Environmental safety hazards
- Inadequate leadership
- Gaps in the continuum of care
- Deficient care planning
- Weak organizational culture
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Description
This quiz focuses on key concepts related to sentinel events in healthcare, emphasizing the historical contributions of Florence Nightingale to nursing and the importance of reducing patient harm. It highlights the foundational principles of patient care and safety standards in hospitals. Test your knowledge on vital nursing practices and guidelines that aim to prevent harm in healthcare settings.
