Sentinel events are unexpected occurrences involving death or serious physical or psychological injury or risk. Examples include suicide, wrong-site surgery, and infant abduction. A sentinel event differs from a medical error in its severity of outcome. Organizations are expected to report sentinel events, conduct a root cause analysis to identify causal factors, implement an action plan to reduce risks, and evaluate compliance through the survey process. The goal is to improve patient safety by learning from sentinel events.
A brief lecture ppt for the students and professionals of Healthcare Quality Management & Patient Safety. This lecture presented in Arar Central Hospital of KSA for CME of doctors & nurses. Sentinel Events topic is a basic topic of Healthcare Quality Management and they can be controlled by caring of International Patient Safety Goals.
The document defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury or risk thereof. It then classifies different types of sentinel events such as unanticipated death, major permanent loss of function, wrong surgery/site/person, and nosocomial infections resulting in unanticipated death or injury. The document explains that when a sentinel event occurs, a response team must conduct a root cause analysis (RCA) to determine the underlying causes. It outlines the five steps of an RCA: defining the problem, understanding what happened, determining the root cause, identifying effective solutions, and following up. Tools like 5 Whys and fishbone diagrams can be used to help uncover root causes. The
Sentinel events are unexpected occurrences in healthcare settings that result in death or serious injury and are more severe than medical errors. They include wrong-site surgeries, hospital-acquired infections, and infant abductions. The Joint Commission defines and tracks sentinel events to conduct root cause analyses and prevent future occurrences. Hospitals must analyze causes and create action plans when sentinel events happen to improve patient safety.
Patient safety is an important part of healthcare. It aims to prevent harm caused by accidents, errors, and complications during treatment. Some key aspects of ensuring patient safety include accurate patient identification, effective communication of medical information, safe medication practices, reducing risks of infections, conducting risk assessments, following safety protocols for radiation and surgery, and maintaining a safe clinic environment. Organizations are working to promote a culture of safety and establish systems to safeguard patients.
An occurrence variance report (OVR) documents incidents in a hospital that deviate from standard practices and could impact patient or staff health and safety. Near misses, where an adverse event was avoided by chance, should also be reported. Basic categories to include on an OVR are medication errors, falls, injuries, complaints, and equipment issues. The quality department is responsible for receiving OVRs within 24 hours, investigating incidents, and ensuring corrective actions are implemented with the involved departments.
This document provides guidelines for various quality and safety practices at a hospital. It discusses proper patient identification procedures, guidelines for verbal and telephone orders, procedures for high alert medications, surgical checklists including site marking and time outs, hand hygiene practices, fall risk assessment and prevention measures, occurrence variance reporting for documenting incidents, and the focus-PDCA methodology for quality improvement. Key areas of focus include correctly identifying patients, improving communication, ensuring surgery and medication safety, reducing healthcare associated infections and patient harm from falls.
This document discusses patient safety and the International Patient Safety Goals. It defines patient safety as the prevention of errors and adverse effects associated with healthcare. It also defines key terms like sentinel events and near misses. The document then summarizes each of the 6 International Patient Safety Goals which focus on correctly identifying patients, improving communication, safety of high-alert medications, correct site surgery, reducing healthcare associated infections, and reducing falls. It provides examples of processes to meet each goal.
A brief lecture ppt for the students and professionals of Healthcare Quality Management & Patient Safety. This lecture presented in Arar Central Hospital of KSA for CME of doctors & nurses. Sentinel Events topic is a basic topic of Healthcare Quality Management and they can be controlled by caring of International Patient Safety Goals.
The document defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury or risk thereof. It then classifies different types of sentinel events such as unanticipated death, major permanent loss of function, wrong surgery/site/person, and nosocomial infections resulting in unanticipated death or injury. The document explains that when a sentinel event occurs, a response team must conduct a root cause analysis (RCA) to determine the underlying causes. It outlines the five steps of an RCA: defining the problem, understanding what happened, determining the root cause, identifying effective solutions, and following up. Tools like 5 Whys and fishbone diagrams can be used to help uncover root causes. The
Sentinel events are unexpected occurrences in healthcare settings that result in death or serious injury and are more severe than medical errors. They include wrong-site surgeries, hospital-acquired infections, and infant abductions. The Joint Commission defines and tracks sentinel events to conduct root cause analyses and prevent future occurrences. Hospitals must analyze causes and create action plans when sentinel events happen to improve patient safety.
Patient safety is an important part of healthcare. It aims to prevent harm caused by accidents, errors, and complications during treatment. Some key aspects of ensuring patient safety include accurate patient identification, effective communication of medical information, safe medication practices, reducing risks of infections, conducting risk assessments, following safety protocols for radiation and surgery, and maintaining a safe clinic environment. Organizations are working to promote a culture of safety and establish systems to safeguard patients.
An occurrence variance report (OVR) documents incidents in a hospital that deviate from standard practices and could impact patient or staff health and safety. Near misses, where an adverse event was avoided by chance, should also be reported. Basic categories to include on an OVR are medication errors, falls, injuries, complaints, and equipment issues. The quality department is responsible for receiving OVRs within 24 hours, investigating incidents, and ensuring corrective actions are implemented with the involved departments.
This document provides guidelines for various quality and safety practices at a hospital. It discusses proper patient identification procedures, guidelines for verbal and telephone orders, procedures for high alert medications, surgical checklists including site marking and time outs, hand hygiene practices, fall risk assessment and prevention measures, occurrence variance reporting for documenting incidents, and the focus-PDCA methodology for quality improvement. Key areas of focus include correctly identifying patients, improving communication, ensuring surgery and medication safety, reducing healthcare associated infections and patient harm from falls.
This document discusses patient safety and the International Patient Safety Goals. It defines patient safety as the prevention of errors and adverse effects associated with healthcare. It also defines key terms like sentinel events and near misses. The document then summarizes each of the 6 International Patient Safety Goals which focus on correctly identifying patients, improving communication, safety of high-alert medications, correct site surgery, reducing healthcare associated infections, and reducing falls. It provides examples of processes to meet each goal.
The document discusses patient safety definitions, goals, and best practices. It defines patient safety as working to avoid, manage, and treat unsafe acts in healthcare through the use of best practices leading to optimal patient outcomes. The goals are to provide a safe environment for all individuals by promoting a proactive, non-punitive culture that facilitates reporting of hazards, errors, near-misses, and other unsafe conditions. Key aspects that should be reported include unanticipated outcomes, infections, errors, near misses, and safety concerns. Effective communication, identifying patients correctly, improving medication safety, ensuring correct procedures, reducing infections, and mitigating fall risks are emphasized as important areas of focus.
The document outlines the policies and procedures of a hospital's patient safety plan. It establishes a patient safety committee to identify risks, prevent medical errors, and improve safety. It defines key terms like adverse events, near misses, and medication errors. It also lists the standard safety policies the hospital has implemented covering areas like clinical care, medication management, infection control, and facility maintenance. The goal is to institutionalize patient safety as a fundamental part of healthcare delivery.
This document defines sentinel events as unanticipated events in healthcare settings resulting in death or serious injury to patients not related to their illness. It lists types of sentinel events including surgical events, product/device events, patient protection events, care management events, environmental events, and criminal events. Root causes of sentinel events are typically systemic problems like poor communication or assessment. When one occurs, the patient's safety and a thorough investigation are prioritized, with the goal of developing an action plan to prevent future occurrences.
This document provides an overview of incident reporting in a healthcare facility. It defines an incident and the main types: near misses, adverse events, and sentinel events. Near misses have the potential to cause harm but do not, while adverse events do cause unintended harm. Sentinel events result in major loss of function or death. The presentation outlines how and when to report each type of incident and the importance of reporting near misses to prevent future harm. It also describes the root cause analysis process used to determine why failures occurred and how to submit an accurate and thorough incident report.
Patient safety is a fundamental principle of healthcare. Adverse events can result from problems in various areas of care and improving safety requires a complex, system-wide effort. Ensuring safety involves assessing risks, preventing harm, reporting and analyzing incidents, learning from mistakes, and implementing solutions. Guidelines include proper identification of patients, hand hygiene, medication reconciliation, and fall prevention.
The document discusses patient safety in healthcare. It defines patient safety and identifies common medical errors. The goals are to establish a culture of safety, minimize errors, and implement standardized practices and reporting. A patient safety committee coordinates these efforts by managing risk, establishing reporting procedures, and collecting/analyzing safety data to identify root causes and implement corrective actions. The leadership role is to create an environment that recognizes safety importance and implements a patient safety program.
The document discusses the purpose and definitions related to occurrence variance reporting (OVR) in hospitals. The key points are:
1. The aims of OVR reporting are to positively impact patient care, services, and safety by learning from incidents and preventing future occurrences.
2. Sentinel events are unexpected occurrences that result in death or major loss of function for a patient and are always considered severe adverse events.
3. Mandatory reportable events that require notification within 24 hours include wrong site surgeries, retained surgical items, and transfusion reactions.
4. OVR reports should be written and submitted by the charge person to hospital management within 24 hours of an occurrence. Confidentiality is emphasized
Patient safety- To err is human, building safer health system -IPSGLallu Joseph
The document discusses patient safety in hospitals. It notes that hospitals are complex organizations to manage and medical errors cannot happen. It discusses the importance of teamwork in hospitals and how quality management and accreditation can enhance teamwork. Several international patient safety goals are described, including properly identifying patients, improving communication, safely handling high-alert medications, ensuring safe surgery, reducing healthcare-associated infections, and reducing the risk of patient falls. Building a culture of safety is also emphasized through leadership commitment, encouraging reporting, training, and prioritizing safety issues. The document concludes by reminding readers to treat all patients like family.
A part from an incident, accident or a sentinel event, OVR would implement events, that should be of a mandatory sstep, for accreditation of health institutions.
The document outlines the policies and procedures for reporting occurrences and sentinel events at a hospital using Occurrence Variance Reports (OVR). It states that OVRs should be completed by staff to document any incidents, injuries, or issues. Sentinel events involving major patient harm or death require special reporting to the Quality Improvement Coordinator and Sentinel Event Committee for a root cause analysis and action plan. The Total Quality Management Department monitors OVRs, identifies trends, and reports to relevant committees to prevent future issues. All occurrence reporting and investigation information is kept confidential by the TQM department.
This document introduces the concept of patient safety and discusses occurrence variance reporting (OVR) and international patient safety goals. It notes that medical errors injure 1 in 25 hospital patients and kill 44,000-98,000 people per year in the US. The goals of patient safety are to detect safety issues, implement preventive actions, and reduce risks. OVR involves voluntary reporting of process variations to improve quality and prevent recurrences. It identifies adverse events, near misses, and sentinel events. The six international patient safety goals focus on correctly identifying patients, improving communication, increasing medication safety, ensuring correct surgical procedures, reducing healthcare-associated infections, and decreasing falls.
Patient safety goals effective january 1, 2016Hisham Aldabagh
Includes the patient safety goals which must be achieved during the year 2016, focusing on patient identification, proper patient medication, protection patient against infection, and strict per operative patient safety procedures
This document defines key terms related to occurrence variance reporting (OVR) like occurrence, sentinel event, near miss, malpractice, and adverse event. It outlines the objectives, definitions, reporting process, roles and responsibilities, and procedures for completing an OVR form. The goal of the OVR system is to document details of any event that negatively impacts patient care, identify root causes, and implement corrective actions through a non-punitive process. It aims to act as a quality improvement tool for monitoring and preventing future occurrences.
Patient safety aims to prevent harm caused by healthcare itself. While most medical care is delivered safely, errors still occur and patient safety has increasingly been recognized as an important global issue, though more work is needed to address it. Common causes of harm include individual errors, system issues, and environmental factors, and strategies like checklists and protocols seek to improve safety.
The document outlines international patient safety goals and guidelines for incident reporting. It discusses 6 main safety goals, including correctly identifying patients, improving communication, and reducing healthcare-associated infections. It also defines different types of incidents like near misses, adverse events, and sentinel events. For reporting, it specifies the immediate actions required and that all incidents must be reported to the quality department within 24 hours. The purpose is to distinguish between different adverse events to improve patient safety.
Introduction to Continous Quality ImprovementGina Ingrouille
This document provides an agenda and overview for a training on continuous quality improvement. The training will cover topics such as what accreditation and CQI are, why they are important, how to engage in the PDCA model of change, using policies and procedures, and reviewing health and community service standards. Participants will have exercises to practice applying CQI concepts and evaluating their organization's processes. They will also learn how to find information in policies and procedures. The goal is to help organizations demonstrate CQI and prepare for accreditation.
This document discusses medical audits and provides information on various types of audits including internal and external audits, managerial/organizational audits, medical/clinical audits, and financial audits. It explains the need for audits to maintain safety, quality, reputation and funding. The document outlines the six stages of clinical audits including preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-auditing. Methods used in audits like direct observation, checklists, documentation reviews, questionnaires and interviews are also mentioned.
This document outlines six international patient safety goals for healthcare organizations. The goals are to: 1) identify patients correctly using at least two patient identifiers; 2) improve effective communication among caregivers by writing down and reading back verbal orders; 3) improve safety of high-alert medications by addressing storage of concentrated electrolytes; 4) ensure correct-site, correct-procedure, correct-patient surgery through verification and timeout procedures; 5) reduce healthcare-associated infections through hand hygiene policies and programs; and 6) reduce risk of falls through assessment and risk reduction measures for at-risk patients. Requirements are provided for each goal.
The document outlines the international patient safety goals established by the Joint Commission International in 2007. The six goals are: 1) Identify patients correctly to prevent medical errors, 2) Improve communication among staff to ensure accurate information exchange, 3) Improve safety practices for high alert medications, 4) Ensure the correct patient, site, and procedure for surgeries, 5) Reduce healthcare associated infections through proper hand hygiene, and 6) Reduce the risk of patient falls through risk assessment and prevention efforts. Details are provided on protocols for each goal around identification, documentation, high risk drugs, surgery verification, and fall prevention.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
The document discusses patient safety definitions, goals, and best practices. It defines patient safety as working to avoid, manage, and treat unsafe acts in healthcare through the use of best practices leading to optimal patient outcomes. The goals are to provide a safe environment for all individuals by promoting a proactive, non-punitive culture that facilitates reporting of hazards, errors, near-misses, and other unsafe conditions. Key aspects that should be reported include unanticipated outcomes, infections, errors, near misses, and safety concerns. Effective communication, identifying patients correctly, improving medication safety, ensuring correct procedures, reducing infections, and mitigating fall risks are emphasized as important areas of focus.
The document outlines the policies and procedures of a hospital's patient safety plan. It establishes a patient safety committee to identify risks, prevent medical errors, and improve safety. It defines key terms like adverse events, near misses, and medication errors. It also lists the standard safety policies the hospital has implemented covering areas like clinical care, medication management, infection control, and facility maintenance. The goal is to institutionalize patient safety as a fundamental part of healthcare delivery.
This document defines sentinel events as unanticipated events in healthcare settings resulting in death or serious injury to patients not related to their illness. It lists types of sentinel events including surgical events, product/device events, patient protection events, care management events, environmental events, and criminal events. Root causes of sentinel events are typically systemic problems like poor communication or assessment. When one occurs, the patient's safety and a thorough investigation are prioritized, with the goal of developing an action plan to prevent future occurrences.
This document provides an overview of incident reporting in a healthcare facility. It defines an incident and the main types: near misses, adverse events, and sentinel events. Near misses have the potential to cause harm but do not, while adverse events do cause unintended harm. Sentinel events result in major loss of function or death. The presentation outlines how and when to report each type of incident and the importance of reporting near misses to prevent future harm. It also describes the root cause analysis process used to determine why failures occurred and how to submit an accurate and thorough incident report.
Patient safety is a fundamental principle of healthcare. Adverse events can result from problems in various areas of care and improving safety requires a complex, system-wide effort. Ensuring safety involves assessing risks, preventing harm, reporting and analyzing incidents, learning from mistakes, and implementing solutions. Guidelines include proper identification of patients, hand hygiene, medication reconciliation, and fall prevention.
The document discusses patient safety in healthcare. It defines patient safety and identifies common medical errors. The goals are to establish a culture of safety, minimize errors, and implement standardized practices and reporting. A patient safety committee coordinates these efforts by managing risk, establishing reporting procedures, and collecting/analyzing safety data to identify root causes and implement corrective actions. The leadership role is to create an environment that recognizes safety importance and implements a patient safety program.
The document discusses the purpose and definitions related to occurrence variance reporting (OVR) in hospitals. The key points are:
1. The aims of OVR reporting are to positively impact patient care, services, and safety by learning from incidents and preventing future occurrences.
2. Sentinel events are unexpected occurrences that result in death or major loss of function for a patient and are always considered severe adverse events.
3. Mandatory reportable events that require notification within 24 hours include wrong site surgeries, retained surgical items, and transfusion reactions.
4. OVR reports should be written and submitted by the charge person to hospital management within 24 hours of an occurrence. Confidentiality is emphasized
Patient safety- To err is human, building safer health system -IPSGLallu Joseph
The document discusses patient safety in hospitals. It notes that hospitals are complex organizations to manage and medical errors cannot happen. It discusses the importance of teamwork in hospitals and how quality management and accreditation can enhance teamwork. Several international patient safety goals are described, including properly identifying patients, improving communication, safely handling high-alert medications, ensuring safe surgery, reducing healthcare-associated infections, and reducing the risk of patient falls. Building a culture of safety is also emphasized through leadership commitment, encouraging reporting, training, and prioritizing safety issues. The document concludes by reminding readers to treat all patients like family.
A part from an incident, accident or a sentinel event, OVR would implement events, that should be of a mandatory sstep, for accreditation of health institutions.
The document outlines the policies and procedures for reporting occurrences and sentinel events at a hospital using Occurrence Variance Reports (OVR). It states that OVRs should be completed by staff to document any incidents, injuries, or issues. Sentinel events involving major patient harm or death require special reporting to the Quality Improvement Coordinator and Sentinel Event Committee for a root cause analysis and action plan. The Total Quality Management Department monitors OVRs, identifies trends, and reports to relevant committees to prevent future issues. All occurrence reporting and investigation information is kept confidential by the TQM department.
This document introduces the concept of patient safety and discusses occurrence variance reporting (OVR) and international patient safety goals. It notes that medical errors injure 1 in 25 hospital patients and kill 44,000-98,000 people per year in the US. The goals of patient safety are to detect safety issues, implement preventive actions, and reduce risks. OVR involves voluntary reporting of process variations to improve quality and prevent recurrences. It identifies adverse events, near misses, and sentinel events. The six international patient safety goals focus on correctly identifying patients, improving communication, increasing medication safety, ensuring correct surgical procedures, reducing healthcare-associated infections, and decreasing falls.
Patient safety goals effective january 1, 2016Hisham Aldabagh
Includes the patient safety goals which must be achieved during the year 2016, focusing on patient identification, proper patient medication, protection patient against infection, and strict per operative patient safety procedures
This document defines key terms related to occurrence variance reporting (OVR) like occurrence, sentinel event, near miss, malpractice, and adverse event. It outlines the objectives, definitions, reporting process, roles and responsibilities, and procedures for completing an OVR form. The goal of the OVR system is to document details of any event that negatively impacts patient care, identify root causes, and implement corrective actions through a non-punitive process. It aims to act as a quality improvement tool for monitoring and preventing future occurrences.
Patient safety aims to prevent harm caused by healthcare itself. While most medical care is delivered safely, errors still occur and patient safety has increasingly been recognized as an important global issue, though more work is needed to address it. Common causes of harm include individual errors, system issues, and environmental factors, and strategies like checklists and protocols seek to improve safety.
The document outlines international patient safety goals and guidelines for incident reporting. It discusses 6 main safety goals, including correctly identifying patients, improving communication, and reducing healthcare-associated infections. It also defines different types of incidents like near misses, adverse events, and sentinel events. For reporting, it specifies the immediate actions required and that all incidents must be reported to the quality department within 24 hours. The purpose is to distinguish between different adverse events to improve patient safety.
Introduction to Continous Quality ImprovementGina Ingrouille
This document provides an agenda and overview for a training on continuous quality improvement. The training will cover topics such as what accreditation and CQI are, why they are important, how to engage in the PDCA model of change, using policies and procedures, and reviewing health and community service standards. Participants will have exercises to practice applying CQI concepts and evaluating their organization's processes. They will also learn how to find information in policies and procedures. The goal is to help organizations demonstrate CQI and prepare for accreditation.
This document discusses medical audits and provides information on various types of audits including internal and external audits, managerial/organizational audits, medical/clinical audits, and financial audits. It explains the need for audits to maintain safety, quality, reputation and funding. The document outlines the six stages of clinical audits including preparing, selecting criteria, measuring performance, making improvements, sustaining improvements, and re-auditing. Methods used in audits like direct observation, checklists, documentation reviews, questionnaires and interviews are also mentioned.
This document outlines six international patient safety goals for healthcare organizations. The goals are to: 1) identify patients correctly using at least two patient identifiers; 2) improve effective communication among caregivers by writing down and reading back verbal orders; 3) improve safety of high-alert medications by addressing storage of concentrated electrolytes; 4) ensure correct-site, correct-procedure, correct-patient surgery through verification and timeout procedures; 5) reduce healthcare-associated infections through hand hygiene policies and programs; and 6) reduce risk of falls through assessment and risk reduction measures for at-risk patients. Requirements are provided for each goal.
The document outlines the international patient safety goals established by the Joint Commission International in 2007. The six goals are: 1) Identify patients correctly to prevent medical errors, 2) Improve communication among staff to ensure accurate information exchange, 3) Improve safety practices for high alert medications, 4) Ensure the correct patient, site, and procedure for surgeries, 5) Reduce healthcare associated infections through proper hand hygiene, and 6) Reduce the risk of patient falls through risk assessment and prevention efforts. Details are provided on protocols for each goal around identification, documentation, high risk drugs, surgery verification, and fall prevention.
In the presentation, a summary of initiatives to be taken by hospitals in different areas for patient safety have been described for the knowledge, practices and implementation of patient safety initiative by hospital managers/Administrators.
The document discusses various types of health care indices and registries that are used to collect and aggregate patient data. Indices include master patient indices, disease indices, procedure indices, and physician indices. Registries include admission, discharge, birth, death, cancer, and trauma registries. The summaries provide high-level information on what data each collects and how the data can be accessed.
The document discusses medical errors and patient safety. It notes that medical errors result in tens of thousands of deaths each year in the US, costing billions of dollars. Underreporting of errors is a problem due to fear of punishment and a "sweep it under the rug" attitude. National organizations are working to improve safety through initiatives to reduce infections, falls, and other hospital events. Reporting of errors and "near misses" can help analyze root causes and improve systems to prevent future occurrences.
CPC, a leader in captioning technology, relies on SafeNet Sentinel HASP to protect and license its software. Sentinel HASP allows CPC to license its $2,000-$9,000 software to single machines, preventing unauthorized use. This protects CPC's revenue and intellectual property. Sentinel HASP also makes it easy for CPC to remotely update software licenses and upgrade keys for new software versions, allowing CPC to adapt to changing technologies while maintaining protection. Using Sentinel HASP, CPC can offer innovative captioning software securely without risk of being unprotected.
This document discusses medical error reduction presented by Mrs. Leela Baby. It identifies common types of medical errors and emphasizes creating a blame-free culture to accurately report errors. Factors that increase medical error risks are examined, such as complex technology, multiple caregivers, and high patient acuity. Root cause analysis and sentinel event reviews are presented as tools to diagnose error-inducing conditions. Solutions proposed include accurate patient identification, hand hygiene, and reporting all errors to evaluate and improve the system. The overall message is the importance of doing services right the first time to prevent errors.
The process of diagnosing product problems identified during design, manufacture or use brings many challenges. The presentation will discuss ways to alleviate these difficulties using a structured, troubleshooting-based approach, and being aware of some common errors and ways of dealing with them.
• How to analyze data for low frequency failures
• Using the information from RCA for improving both prevention and detection
• Understand why finding a product solution often isn’t enough
The document outlines the International Patient Safety Goals (IPSG) which are aimed at reducing common causes of medical errors and improving patient safety. It discusses the goals of correctly identifying patients, improving communication effectiveness, improving safety of high-alert medications, ensuring correct surgery procedures, reducing healthcare-associated infections, and reducing risks of patient harm from falls. For each goal, it provides more details on the specific processes and standards involved in achieving that goal.
This document provides an overview of the anatomy and physiology of the gastrointestinal system and its components. It discusses the mouth, esophagus, stomach, small intestine, large intestine, liver, gallbladder and pancreas. It also reviews common laboratory procedures related to the GI system like fecalysis, upper and lower GI studies, and endoscopy. Common GI symptoms like constipation, diarrhea and dumping syndrome are discussed along with nursing interventions.
The document discusses the musculo-skeletal system including its main components and functions. It describes the three types of muscles, tendons, ligaments, bones, joints, and cartilages. It then discusses the assessment of the musculo-skeletal system including history taking, physical examination, common tests like bone marrow aspiration and arthroscopy, and common musculoskeletal problems and their nursing management.
JJ is a 76-year-old female with depression, anxiety, bipolar disorder and chronic sciatica pain who owns a gun shop, lives independently with her husband and attends support groups daily. She has motor, emotional regulation, cognitive, and social dysfunction impacting her activities of daily living. The occupational therapy treatment plan focuses on relaxation techniques, thought journaling, visual imagery, task analysis and strengthening activities to help JJ better manage her depression and chronic pain.
This document summarizes a medical case involving a 27-year-old African American female patient who presents with migraines, fatigue, and dysmennorhea. Her medical history and lab results are presented. The assistant recommends switching the patient's migraine medication from oral tablets to nasal spray, adjusting a pain medication, treating her anemia with iron supplements, addressing her obesity through diet and exercise, and considering preventative migraine treatments.
The musculoskeletal system consists of two main systems - the skeletal system and the muscular system. The three types of muscles are smooth, skeletal, and cardiac muscles. Skeletal muscles are voluntary muscles that produce movement and are attached to bones via tendons. Bones provide structure, protect organs, allow movement, produce blood cells, and store minerals. The skeletal system works with skeletal muscles to provide functions like protection, support, movement, and mineral storage.
ADVERSE DRUG REACTIONS_LASUCOM LECTURE.pptMautonSamuel1
1) Adverse drug reactions (ADRs) are unintended harmful effects of drugs that occur at normal dosages for treatment or diagnosis. They can range from mild to severe or life-threatening.
2) Thalidomide caused birth defects in the late 1950s when taken by pregnant women for morning sickness, highlighting limitations of pre-market drug testing like short duration and narrow populations studied.
3) ADRs are classified based on onset, severity, and type. Type A reactions are dose-dependent and predictable while Type B are unpredictable and potentially life-threatening. Causality assessment considers factors like temporal relationship and de-challenge/re-challenge responses.
This document provides an overview of medication safety and medication errors. It defines key terms like medical error, adverse drug events, and near misses. It discusses the scale of medication errors, estimating they occur in 5-14% of doses dispensed and 1 in 100 result in an adverse drug event. Preventable medical errors occur in over 3 million hospital admissions and outpatient visits annually in the US, resulting in over 7,000 deaths each year. Factors that contribute to medication errors include complex medication regimens and lack of communication between healthcare providers. Strategies to improve safety include using generic drug names, tailoring prescriptions to each patient, thorough medication histories, awareness of high-risk medications, and encouraging patient involvement.
Reducing Antipsychotic Drug Use for DementiaLeadingAge
This document discusses reducing unnecessary antipsychotic medication use in dementia patients. It begins by outlining the risks of antipsychotic medications, including an FDA black box warning about increased mortality in elderly patients with dementia. It then discusses initiatives by CMS and others to reduce off-label and unnecessary antipsychotic use by 15% through improved behavioral interventions and regulatory oversight. The document emphasizes using a non-pharmacological ABC approach and emphasizes improving care through staff education, careful medication reviews, and data tracking of antipsychotic use.
This document discusses various topics in medical ethics including duties of medical practitioners towards patients, informed consent, negligence, euthanasia, and professional misconduct. It outlines that medical ethics establishes moral principles for doctors in their dealings with patients, colleagues, and the state. Doctors have duties to treat patients, maintain confidentiality, obtain informed consent, and notify authorities of certain diseases. Professional negligence can occur through absence of reasonable care resulting in injury. Euthanasia refers to mercy killing through passive or active means, which is legal in some countries under certain conditions.
This document discusses engaging the medical community on the issue of opioid use and abuse. It begins with introductions from Brian Fingerson, President of Kentucky Professionals Recovery Network, and Dallas Gay, Co-chair of the Medical Association of Georgia Foundation's "Think About It" Campaign. The speakers then review learning objectives about describing changing attitudes around prescription drug abuse, defining clinicians' roles in positively impacting the opioid epidemic, and demonstrating programs that are engaging the clinical community on appropriate opioid use and abuse.
Medication safety is important to prevent patient harm from errors. Factors that contribute to errors include inadequate medication histories, lack of communication between providers, ambiguous labeling, and failure to double check medications. Efforts to improve safety include using generic names, tailoring prescriptions to each patient, knowing high-risk medications, developing checking habits, and encouraging patient involvement in their own care.
Drugs and the Body discusses the pharmacokinetics and pharmacodynamics of how drugs act on the body. Pharmacokinetics describes the absorption, distribution, metabolism and excretion of drugs in the body. Pharmacodynamics examines how drugs produce their effects by interacting with receptor sites or replacing missing chemicals. Nursing management of drug administration involves ensuring the "rights" of giving the right drug to the right patient via the right route and dose. The nursing process - which includes assessment, nursing diagnosis, planning, interventions and evaluation - is used to properly manage a patient's drug therapy.
Drug Safety is the science relating to collection, detection, assessment, monitoring and prevention of adverse effects with pharmaceutical products. It mainly focuses on adverse drug reactions
CRITICAL INCIDENT REPORTING IN ANAESTHESIA.pptxOlachiUba1
This document discusses critical incident reporting in anaesthesia, with a focus on drug errors. It begins by defining critical incidents and near misses in anaesthesia. It then discusses the causes of critical incidents, including human errors and latent failures. The document outlines the components of an effective incident reporting system, including independent reporting, analysis by subject matter experts, and feedback. It analyzes reported incidents to identify areas for improvement. Drug errors are defined and classified, with risk factors and consequences discussed. The prevention of drug errors focuses on vigilance, standardized protocols, and thinking before acting.
The document summarizes key principles regarding professional behavior and ethics for physicians. It discusses appropriate boundaries in physician-patient relationships, informed consent, medical errors and liability, and obligations to report issues like abuse or impaired colleagues. Physicians must prioritize patient welfare, maintain open communication, and follow standards of care to practice ethically and avoid legal issues.
The document discusses medical negligence, providing definitions and examples. It defines professional negligence as the absence of reasonable care by a medical practitioner that causes bodily injury or death. It notes negligence is a breach of the duty to provide proper care. The document outlines the four D's of negligence: duty, dereliction, damage, and direct causation. It provides examples of negligence through both acts of omission and commission. It also discusses defenses against negligence claims and the difference between civil and criminal negligence.
This document defines and classifies adverse drug reactions and drug-related harms. It discusses predictable and unpredictable reactions, side effects versus adverse effects, and different types of reactions including hypersensitivity, idiosyncrasy, toxicity and dependence. It also covers teratogenicity, pharmacovigilance, and methods for monitoring and reporting adverse drug reactions.
This document discusses the importance of nursing documentation and how a nurse's license may depend on thorough and accurate documentation. It notes that poor documentation can lead to malpractice lawsuits and loss of a nursing license. The document provides examples of legal cases where nurses faced consequences due to deficiencies in their documentation. It emphasizes that if an action is not documented, it is considered as if it was not performed.
This document discusses medication errors and adverse drug reactions (ADRs). It defines medication errors as preventable events that may lead to inappropriate medication use or harm, and defines ADR harm. It then categorizes common types of medication errors and describes the differences between ADRs, drug interactions, and adverse drug events. It also discusses factors that can contribute to ADRs and lists different classifications of ADRs including by severity and type.
PN 1080 Unit 1 Intro to Pathophysiology.pptxRachelBurwell1
This document provides an overview of pathophysiology and key concepts related to the study of disease. It defines pathophysiology as the functional changes that occur in the body as a result of disease. For each disease studied, pathophysiology examines the normal anatomy and physiology, classification, causes, signs and symptoms, diagnostic tests, complications, and treatment. Homeostasis and its relationship to health and disease is also discussed. The document then covers various aspects of disease such as prevention, terminology, disease processes, characteristics, cellular adaptations, causes of cell damage, types of necrosis, and more.
The document discusses the Yellow Card Scheme in the UK for reporting adverse drug reactions (ADRs). It defines an ADR and describes how common ADRs are, causing 6.5% of adult hospital admissions. It outlines how ADRs can be classified and factors that influence them. The Yellow Card Scheme acts as an early warning system to identify new ADRs and risks. Healthcare professionals, patients and the public can report suspected ADRs to the scheme to help continual drug safety monitoring.
This document discusses unnecessary medications and adverse drug events in elderly patients. It defines unnecessary medications as those with excessive doses, durations, lack of monitoring or indications. Adverse drug events are defined as preventable issues that occur during ordering, monitoring or administration of medications. Common causes of adverse drug events include drug-drug interactions, toxicity and failure to consider a patient's condition. The document emphasizes the importance of comprehensive assessment, monitoring and care planning to prevent unnecessary medication use and adverse drug events in elderly patients.
Pharmacovigilance is the science of detecting, assessing, understanding, and preventing adverse effects of medicines. The goals of pharmacovigilance include early detection of unknown safety problems, quantifying risks, and preventing patients from being harmed. Adverse drug reactions are a major cause of mortality and healthcare costs worldwide. Ongoing pharmacovigilance is needed to monitor drug safety after approval and promote rational, safer drug use. Healthcare professionals play a key role by thoroughly investigating and reporting any suspected adverse drug reactions.
Fall prevention for the Elderly Population | VITAS HealthcareVITAS Healthcare
Falls are the leading cause of injury for elderly adults. One in three adults over 65 falls each year, and falls are the cause of half of all trauma deaths among elderly patients. Nursing home residents are at especially high risk, with 30-40% sustaining significant falls. A comprehensive assessment identifies medical, environmental, and personal risk factors. A multidisciplinary team implements an individualized care plan with education, exercise, medication management, assistive devices, and environmental safety strategies to prevent falls and injuries among elderly patients.
Fall prevention for the Elderly Population | VITAS Healthcare
Powers Sentinel Event
1.
2. Sentinel Event
Unexpected/unanticipated outcome
• Death
• Serious physical/phsychological injury or risk
• Examples:
– Loss of limb or function
– Patient on suicide watch commits suicide
– Unexpected death of full-term infant
– Infant abduction
– Infant discharged to wrong family
– Rape
– Reaction to mismatched blood
– Surgery on wrong patient/wrong body part
3. Difference Between Medical Error &
Sentinel Event
Medical Error: Sentinel Event:
– 44,000 and 98,000 Americans die – Death
each year – Physical/phsychological injury or risk
• Loss of limb or function
• Common Medical Errors • Suicide
– Incorrect administration of
• Rape
medication
• Infant death
– Dosage or route of
administration • Infant discharged to wrong parents
– Failure to prescribe or administer • Surgery on wrong patient, or body part
correct drug • Incorrectly matched blood transfusion
– Use of outdated drugs – 1,900 sentinel events reviewed by the Joint
– Failure to observe correct time Commission since January 1995
– Lack awareness of adverse – Patient suicide accounted for 16.5% of the errors
effects.
– Operative/post-operative complication – 12.3%
– Hard to read handwritten orders
– Different drugs – Wrong-site surgery – 11.7
– Drug allergies
– Medication error – 11.5
4. Sentinel Event Policy
• To have a positive impact in improving patient care, treatment, and
services and preventing sentinel events
• To focus the attention of a disease-specific care program that has
experienced a sentinel event
• understanding contributed factors to an event (such as underlying
causes, latent conditions, and active failures in defense systems or
organizational cultures)
• disease-specific care program’s systems, culture, and processes to
reduce the probability of such an event in the future
• To increase the general knowledge about sentinel events, their
contributing factors, and strategies for prevention
• To maintain the confidence of the public and certified programs in the
certification process
5. Expectations for Organizations
• Reporting:
– Root Cause Analysis
• Process to identify basic or causal factors of
sentinel events current or in future
– Action Plan
• Plan to identify strategies to implement
reduced risk of sentinel events
– Survey Process
• Evaluate the facilities compliance with
applicable standards
• Score performance
6. Sentinel Event is Identified:
• Surveyor reporting steps:
– Inform the CEO
• Sentinel event identified
• Reported to Joint Commission for review and
follow up
– Review process for responding to sentinel event
– Interview leaders
– Get examples of root cause analysis
» Examples can include closed cases or a near
miss
7. In Summary
• Sentinel Event: • Reporting:
– Unexpected – Classify and respond to sentinel
• Death event
• Physical/phsychological injury or risk • Root cause analysis
– Loss of limb or function • Action plan
– Suicide • Implement improvements
– Rape
– Infant death • Medical Error
– Infant discharged to wrong parents – Incorrect administration of medication
– Surgery on wrong patient, or body • Dosage or route of administration
part
• Failure to prescribe or administer
– Incorrectly matched blood
transfusion correct drug
• Use of outdated drugs
• Policy:
• Failure to observe correct time
• Improving
• Patient care • Lack awareness of adverse effects.
– Hard to read handwritten orders
• Treatment
– Different drugs
• Services
– Drug allergies
• Preventing sentinel events
• Focus on disease specific care
• Increase knowledge
Editor's Notes
Slide 1:Hello, my name is Lori Powers, I want to thank you all for listening to my presentation. Today my presentation is on Sentinel Events. It is my hopes that after this presentation you will have a better understanding of what a sentinel even is, and what constitutes a sentinel event. With this knowledge we, in the healthcare field, will be better able to stop preventable events, and treat unforeseeable sentinel events when they happen. With that said let’s get started. NEXT SLIDE
The definition of Sentinel event is: CLICK And event that is unexpected and/or unanticipated event which has an outcome of death or serious physical or psychological injury, this includes the risk of a sentinel event.CLICK When a sentinel event is discoveredan investigation started. The Joint Commission analyses a disease-specific care programs’ actions in answer to sentinel events in its evaluation process, as appropriate.CLICK ● Serious injury specifically includes loss of limb or function. This includes any process deviation for which a reappearance would carry a substantial chance of a severe adverse effect. CLICK ● these types of events are called “sentinel,” due to the fact that they need instant analysis and reaction. CLICK ● Sentinel events are not the same as medical errors; Sentinel events do not always occur because of a medical error, and not all medical errors will cause in a sentinel event CLICK Some examples of sentinel events are; CLICK The patient is placed on a 24/7 suicide watch, but they commit suicide anyway. CLICKA full-term infant suddenly dies CLICK A baby is discharged to the wrong family CLICK A transfusion is performed on a patient that the blood was not matched correctly CLICK Surgery on the wrong body part, and surgery on the wrong patient NEXT PAGE
44,000 to 98,000 patients die each year from medical errors.So what is a medical error? The incorrect administration of drugs, unreadable drug order, incorrect combination or formulation of drugs for a given condition, unknown allergies to drugs, drugs not given at the right time.CLICK The most common medical errors include: read from slide. CLICK Sentinel Event:A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. CLICK examples of sentinel events; CLICK Read from slide then CLICK Over 1,900 sentinel events are reviewed by Joint Commission since Jan. 1995. According to the Joint Commissions:CLICK “Patient suicide accounted for 16.5% of the errors CLICK Operative/post-operative complication – 12.3% CLICK Wrong-site surgery – 11.7 CLICK Medication error – 11.5” NEXT PAGE
There are 4 goals in the Joint Commission sentinel event policy; I took these directly from the Joint Commission website, some words were changed but overall I let these as is: CLICK1. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events CLICK2. To focus the attention of a disease-specific care program CLICK3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention CLICK4. To maintain the confidence of the public and certified programs in the certification process. NEXT PAGE
Reporting expectations: CLICKCertified facilities should classify and respond properly to all sentinel events happening in their facility or any events related with the services that the facility offers. Responses to Sentinel events include: CLICKRoot Cause Analysis CLICKRoot cause analysis is the process for finding the basic or causal aspects that triggers deviation in performance, counting the incidence or potential occurrence of a sentinel event. A root cause analysis centers largely on systems and procedures, not on singular performance. CLICKAction Plan CLICKThe results of the root cause analysis is an action plan that classifies the tactics that the facility plans to implement in order to lessen the risk of like events happening again. CLICKSurvey Process CLICKWhen performing an accreditation survey, the Joint Commission look at the facilities compliance with the relevant standards and to score those standards on performance all through the facility over a period of. NEXT PAGE
If when conducting the normal survey activities, a sentinel event is identified the surveyor follows these steps: CLICK Inform the CEO that the event has been identified CLICKInform the CEO the event will be reported to the Joint Commission for further review and follow up CLICKReview the organization’s process for responding to a sentinel event CLICKInterview the organization’s leaders and staff about their expectations and CLICK responsibilities for identifying, reporting, and responding to sentinel events CLICKAsk for an example of a root cause analysis that has been conducted in the past year to assess the adequacy of the organization’s process for responding to a sentinel event. CLICKIn selecting an example, the organization may choose a “closed case” or a “near miss”‡ to demonstrate its process for responding to a sentinel event. CLICK FOR NEXT PAGE
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. examples of sentinel events; A patient that is under 24/7 suicide watch manages to commits suicide. An full-term infant dies suddenly A family takes home the wrong baby Rape A transfusion is done with mismatched blood Surgery is performed on the wrong patient Surgery on the wrong body part. Goals of sentinel event policy To improving patient care, treatment, and services and preventing sentinel eventsTo focus the attention of a disease-specific care program changing the disease-specific care program’s systems, culture, and processes To increase the general knowledge about sentinel events, their contributing factors, and strategies To maintain the confidence of the public and certified programs Reporting expectations: classify and respond properly to all sentinel events Appropriate responses root cause analysis;Survey ProcessMedical Error:Medical error: medication is not correctly dispensed, ordered, or administered, incorrect drug is prescribed. The incorrect administration of drugs, unreadable drug order, incorrect combination or formulation of drugs for a given condition, unknown allergies to drugs, drugs not given at the right time. The most common medical errors include: Thank you for taking the time to listen to my presentation. Have a wonderful day.