Root Cause Analysis
A.1 Sentinel Event Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact
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There was no hand off of the cell phone number the mother provided to the pre-op nurse. As there is no documented area on any of the forms for this information, the process relies on verbal handoff and memory of the nurse. There was no alternate phone number available for the nurse to contact the mother or other designee. Recovery Nurse – The patient was transitioned from the operating room to the recovery room. As previously noted, there is no formal hand off process from one area to another within the ambulatory surgical center. The recovery nurse attempted to locate the mother in the waiting area. As noted above, there was no hand off of the mother’s cell phone number or alternate contact information. Discharge Nurse – The recovery nurse brought the patient to the discharge are post recovery. The patient’s mother had still not returned to the hospital. Again there is no formal hand off process to exchange information. The patient was reported to be anxious and crying. A call was received reporting the patient’s father was available in the waiting area. The male was brought to the area and the child was reported to appear comforted by his arrival. Discharge instructions were given and the child was released with the father. There was no reported verification of photo identification. None of the forms in the patients chart identified the father as the contact. There was no verification the male was
Loss of any insurance payout for damages relating to the property (the property requires complete demo and therefore is a total loss). The amount of the loss depends on what the insurer would deem as the value of the structure (RMS does not know the square footage of the property but for a total loss it would be XXX sqft x YYY cost to rebuild (including structure, machinery, equipment, fixtures, floor covering, appliances), plus debris removal (demolition costs) less deductible and less depreciation;
In order to improve the shipping and handling process for the custom surgical packs, I feel that the first step should be evaluating the exact amount of inventory needed for one day operations. Once the exact amount has been accounted for, APH’s management department can use this data to help reduce the quantity of packs in the buffer from one day supply to smaller a number of packs, thus decreasing the expense. This action helps circle back to the main functionary goal of the JIT method, which is the elimination of waste within the company/organization
Based on the information below, Elite Foam, Inc. will need to be set up in Made2Manage under a new vendor number. The current vendor number of 4018 is actively being used by Elite Comfort Solutions, LLC. and should continue reflecting the Newnan remit to address.
Medicare Part A is otherwise called the Hospital Insurance and covers up to 100 days of the Skilled Nursing Facility stay. To be qualified for it the patient first has to have been hospitalized for more than 3 days in a hospital (qualifying hospital stay) so the stay in it would not be considered outpatient. After the hospital stay the doctor that followed the patient in the hospital or the PCP that releases the patient from the hospital needs to write the order for the SNF services. In order for a patient to receive the services from the SNF they have to:
3/22, offer was presented to Ray, Ray will be requesting the vacation that he has accumulated this year and home to take a week before he makes a decision, the SWSP has requested a deadline with response by 3/27/2017. 3/21/17, Salary offer has been requested for Jenkins. 3/20/2017, John will be speaking to Ray Jenkins about the PT sup opportunity at his terminal. 3-17: SWSP on vacation this week, however Ray Jenkins, POR OPSV, has reported he wants the position; 3-10: Late in day SWSP sent 8 applicants to review/interview-Steps have been taken to increase the flow; 3-2: SCM reports they are actively interviewing; 2-24: Position has been posted on the MCO and externally;
This report demonstrates the current financial situation for the Stratton Township Park and makes recommendations for the annual program budget for the next fiscal year. We first show the current annual budget program, indicating line-item details for each function by account and summarizing the park budget as a whole. Second, we find the break-even points for the golf course green fee and the pool admission to determine what the park would have to charge in order to cover expenses of the these operations. Next, we calculate the marginal revenues and expenses to determine the impact of shutting down certain programs in the park. Lastly, this report prepares the revised budget for the upcoming fiscal year based on our recommendations.
On 10/16/2015 I spoke with Kalila Dowden, parent of Kaylee P. at the operation . Ms. Dowden had come to pick her daughter up while I was at operation for the inspection. I spoke with Ms. Dowden in the office. Ms. Dowden stated Shana Myers the teacher of Kaylee had contacted her and stated she believed Kaylee had a seizure on the playground and EMS had been called. Ms. Dowden stated she had told Ms. Myers she was on her way. Ms. Myers stated shortly after arriving at the center EMS had shown up and she had refused care as she believed her daughter did not need to go to the hospital. Ms. Dowden did state she did not take her daughter to the doctor or hospital as her Neurologist is in Dallas and Ms. Dowden states she is aware of what she is suppose
As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare.
Traditionally nurses delivered clinical information about the patient, the clinical events on their shift and the plan of care to the oncoming shift to ensure continuity of care and to make sure that their colleagues were informed about tasks or instructions that needed to be completed by the next shift. This process had a variety of names; report, handover or handoff. The format was often different from unit to unit. It usually took place in an off stage room or office or at a charting station from away from the
At 3 am while the aide had her sleep brake, the patient’s husband called her to help him patient back to because the patient fell out of the bed during her sleep. As per aide, there were no visible injuries and the patient and her husband refused to call 911. Patient‘s PCP notified and patient’s children as well. RN visits scheduled for post fall
I shared this information with the night staff, left contact numbers and names and the Nurse was called the following morning.
With the evolution of healthcare, patient handovers have become not only a concern in Ontario, but an international concern. The handover (or handoff), also known as a critical transfer point, is the communication between units and healthcare teams that involves the transition of patient information. During a period of care, a patient can potentially be treated by multiple healthcare members in various clinical settings across the continuum of care. The handoff can occur between specialized outpatient, emergency, surgical, and intensive care units and include encounters with numerous staff members at each interval. Some nursing units transfer or discharge their patients at a rate of 40-70% everyday (Friesen, White & Byers, 2009). Consequently,
A.Nightingale Community Hospital is attempting to be in complete compliance with Joint Commission’s “communications” standards. Prior to the Joint Commission survey, Nightingale Community Hospital wanted to focus on items UP.01.01.01 through UP.01.03.01 of the Joint Commission handbook. According to the handbook, these items focus on the universal protocols for preventing wrong site, wrong procedure, wrong person surgery (2015). In response to these universal protocols, the hospital implemented a pre-procedure hand-off tool, which is completed and signed off by both the nurse handing off the patient as well as the nurse accepting the patient. The hospital also began
The post-partum section of the women’s department is dedicated mostly for women who have already given birth. Although they have a labor and delivery room set up just in case any surprise or emergency births occur. I was told in my orientation that this room is rarely used and if it does get used than the most of the nurses will be working with that mother in labor. When I came into the hospital to volunteer, I noticed that the room was occupied and the nurses were working on the laboring mother. Since I am not qualified to help out the nurses during this situation, I went to my post at the nurse’s station and watched the phone that is linked to the other patient rooms.
department where the situation could have turned into a sentinel event and most likely a legal matter. As I was checking in and assessing a patient prior to his surgery, I found the patient to be confused