A. Provide a summary of the following aspects of a root cause analysis related to the sentinel event found in the attached Accreditation Audit Case Study – Task 2 Specific artifacts by doing the following:
1. Describe the sentinel event.
2. Explain the roles (i.e. responsibilities, etc.) of the personnel present during the sentinel event.
3. Discuss the barriers that may impede effective interaction among the personnel present during the sentinel event.
a. Propose ways to improve interactions among the personnel present.
4. Discuss a quality improvement tool to be used to conduct the root cause analysis.
B. Outline a corrective action plan to ensure that the sentinel event does not recur by doing the following:
1. Recommend a risk management program or process change to ensure that the sentinel event does not recur.
a. Discuss resources available to support these changes.
C. Acknowledge sources, using in-text citations and references, for content that is quoted, paraphrased, or summarized.
D. Demonstrate professional communication in the content and presentation of your submission.
2
EXECUTIVE SUMMARY
Executive Summary
Christie Giles
Linda Gunn
Western Governors University
January 12, 2022
Table of Contents
Information management 3
Executive summary 3
Status of compliance 3
A correction plan 5
Areas justification 6
References 7
Information management
Executive summary
As the senior leadership team at Nightingale Community Hospital organizes for an accreditation audit, they must analyze their present compliance status. To examine their compliance position, the team requirement have a comprehensive understanding of Joint Commission to ensure that they are following the rules of their accrediting agency. The effort of this investigation would be on information management of Nightingale’s. The assessment would comprise a compliance status for Nightingale’s Information Management, a corrective plan for areas which do not meet Joint Commission norms, and an understanding of the value of Information Management.
Status of compliance
The Joint Commission’s rules include a section on abbreviations, which states that hospitals must avoid using dose descriptions, symbols, abbreviations, or acronyms that are unsuitable. This requirement is met by Nightingale, as evidenced by their Healthcare Policy: Prohibited Abbreviations documentation. All of the forbidden abbreviations stated on the Joint Commission’s Element of Performance are included in Nightingale’s document. The exact specifications about the use of the trailing zero in the usage of medication-related documents are not included in Nightingale’s publication (Nelson, 2012). The hospital’s document also fails to specify when the restricted list is in effect.
Furthermore, by providing consistent terms and meanings, the Nightingale hospital may maximize its compliance also with the Joint Commission norm. While the hospital is successful in addressing proper abbreviation and dose indication, it is lacking in conventional medical terminology information. An Admission Orders form is used at Nightingale Community Hospital. For example, when listing their medication dosing, they appropriately use the trailing and leading zero Joint Commission standard. It also uses standard abbreviations for lab and tests (i.e. EKG). It also specifies the name of substance for non-standard abbreviations.
After assessing Nightingale’s Information Management articles, it can be concluded that Nightingale does not appropriately define the components of complete medical records (Englebright, 2014). There are no supporting documents that demonstrate Nightingale’s compliance with the Joint Commission’s standard in providing patients and employees with an understanding of the components that make up the medical record.
Nightingale’s Admissions Orders form provides some insight into what a patient’s medical records include. This form includes patient allergies, requested orders, medication information, and diagnostic testing information. Per the Joint Commission standard, a medical record must include facts required to support the evaluation and to explain the requested treatment while the Admissions form excels in documenting the services being requested apron admission, the form lacks reasoning for while the admission is being requested. For example, the form does not include previous diagnostic testing, abnormal vitals, or such information that would justify the need for admission. This information is important for continuity of care from one provider to another as the patient transfers care when admitted.
Nightingale’s Admission Orders form requests that all orders be dated and time-stamped. This form complies with the Joint Commission’s guideline that requires that all entries in the medical record are dated.
The Joint Commission requires that hospitals conduct a review of medical records to ensure that documentation is performed promptly and is legible and accurate. Nightingale’s National Patient Safety Goal (NPSG) data shows the hospital’s review of errors in labeling patient specimens and errors in the use of inappropriate abbreviations. While this shows that Nightingale is conducting some review of their accuracy when documenting patient information, it is minimal and their review could improve. The review should expand to assess the hospital’s timeliness, legibility, and authentication.
A correction plan
The communications artifacts used to assess Nightingale’s Information Management show that the hospital is compliant in ensuring the appropriate use of abbreviation and dose designations. However, the hospital will also need to add an element that specifies the standardized terminology and the corresponding definitions to ensure that there is no miscommunication between medical professionals and with patients. One way to do this is by creating a document that serves similar functions to a glossary (Hegge, 2013). The document can be used to establish standard terminology practices. Additionally, the appropriate use of standard terminology can he audited and assessed by reviewing patient charts to ensure that providers and clinical personnel are adhering to the terminology, abbreviations, and symbols that are compliant with the Joint Commissions’ guidelines. Additionally, the hospital would need to ensure that the appropriate terminology document is readily available to the clinic staff. The document can be saved electronically on the hospital’s intranet or posted in each office.
Nightingale does not properly define the components of complete medical records in any of their artifacts used for Information Management. For example, the Admissions Order form does not include all of the components of the patient’s medical records- it does not include the problem list or treatment notes. Consequently, the Admission Order form should be recreated to include more components of the patient’s medical record that would facilitate the transfer of care to another provider (Hegge, 2011). When recreating the document, it should include the patient’s problem list, family history, clinical notes from the provider placing the order that supports the diagnoses, and medication history. Providing all components of the medical record minimizes clinical errors and ensures that the requested services are justified appropriately.
Areas justification
Nightingale does perform an ongoing review of medical records as demonstrated in their NPSG data. However, the hospital could improve on its review by assessing more areas in Information Management. The plan of action in their area includes conducting monthly reviews of provider clinical charts to ensure that the providers are closing their charts on time, their written information is legible, and the included information is supported with the completeness of data and observations. Additionally, this information can be used to coach clinical staff and catch potential mistakes in patients’ medical records that could ultimately lead to patient harm.
References
Englebright. (2014). Defining and incorporating basic nursing care actions into the electronic health record. Journal of Nursing Scholarship, 57.
Hegge. (2011). The lingering presence of the Nightingale legacy. Nursing Science Quarterly, 162.
Hegge, M. (2013). Nightingale’s environmental theory. Nursing science quarterly, 219.
Nelson. (2012). Notes on Nightingale: The influence and legacy of a nursing icon. Cornell University Press.
Accreditation Audit Case Study – Task 2 Artifacts/Sentinel Event Action Plan.pdf
Sentinel Event Action Plan – OIG Guidelines
Action Plan
A detailed action plan that identifies risk reduction strategies must be stated for each root cause identified. If a risk reduction is not warranted for the identified
cause, an explanation is required. A risk reduction plan should also be developed for any other issues identified as opportunities for improvement that were
identified in the analysis but may not be considered root causes. The following components must be addressed: risk reduction strategy, person responsible for
implementation, date of implementation, and measures of effectiveness. The measures of effectiveness are the same as a performance indicator. They should
include anticipated outcome and measure whether or not the action taken was effective.
Root Cause(s)/Opportunity for Improvement(s):
Highlight and summarize the root cause(s)/ Opportunity for Improvement(s) Issue identified during the root cause analysis.
Risk Reduction Strategy:
Outline in detail the action plan steps taken to promote change. Be specific. If you change a policy and procedure, summarize the change that you are making.
Outline how you are going to implement the policy and procedure (e.g., educate staff, perform post test for staff, etc.).
Person(s) Responsible for Implementation:
Identify by title the individual responsible for implementing the particular risk reduction step.
Target date of implementation:
Outline the anticipated date of completion of each identified step. Outline the actual completion date for steps already completed.
Location of implementation:
Improvements to reduce risk should ultimately be implemented in all areas where applicable, not just where the event occurred. Identify where the
improvements will be implemented.
Completion date:
Date the corrective action was implemented.
Measures of Effectiveness/Performance Indicators:
Outline the plan for measuring the effectiveness of each risk reduction strategy.
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It is not to be distributed outside the quality assurance, performance improvement, peer review process.
Indicators must be objective, measurable, and quantifiable. (Use outcome based measurements whenever possible)
Measures of effectiveness need to have the data collection methodology outlined.
Using a random sample? Define random.
Give sample size and method of collecting.
Are you determining effectiveness by observation? Pre-test/post-test? Pilot test? Audit tool? Explain.
Set a target range that reflects the desired range of performance for each indicator
If measurement is not identified, reason must be documented. (*)
All risk reduction measurement strategies will be evaluated and reported to Senior Leadership within 3 months of completed and approved RCA and updated
quarterly.
Root Cause(s)/Opportunity for
Improvement(s):
Risk Reduction Strategies Target
Implementation
Date
Responsible
Party
Location of
Implementation
Completion
Date
Measures of Effectiveness
Measure:
Measure:
Measure:
Measure:
Measure:
Measure:
Measure:
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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state law.
It is not to be distributed outside the quality assurance, performance improvement, peer review process.
Cite any books or journal articles that were considered in developing this action plan:
Accreditation Audit Case Study – Task 2 Artifacts/Sentinel Event Analysis.pdf
Analysis of Key Components
RCA: Child Abduction
Please note that the root cause analysis and action plan must show evidence of an analysis within the key
components as outlined on the root cause analysis matrix for the specific type of event. An area on the
matrix that may not have an identified process breakdown should still be summarized to determine that the
component was evaluated.
Brief description of event
Briefly summarize the circumstances surrounding the occurrence including the patient outcome (e.g., death,
loss of function).
Who participated in the analysis?
Please include a list of all team members that participated in the analysis by position and title. Please DO
NOT include any names!
When did the event occur?
Include the date and time the event took place.
September 14, Thursday at 12:30pm
What area/service was impacted?
Include the full variety of services impacted by the event.
What are the steps in the process, as designed? (Flow Diagram(s))
The organization may provide a Flow Diagram(s) of the steps in the process involving the occurrence. The
organization may also list the key steps involved in the specific processes relating to the event. Ask–are all
issues in the flow addressed? Suggestions are outlined below.
This is how the process currently works.
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statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.
What human factors were relevant to the event?
Evaluate the role of human performance factors that may have contributed to an error.
Parent Registers Child
Parent and Child taken to pre-op areas
by RN and prepared for surgery (pre-op
assessment done and consent signed)
Parent can accompany child to
door of OR suite
Post op, child transferred to recovery
area
Once stabilized, parent and
child reunited
Discharge teaching done and child
discharged with parents once recovered
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Confidential—For internal use only to support performance improvement activities. This information is provided within the confidentiality protections of state
statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.
How could equipment performance affect the outcome?
List the various equipment utilized for that patient during the healthcare stay. To assist in evaluating these
processes consider the following: Were bio-med checks done and up-to-date? Was the equipment where it
was supposed to be? Why or why not? Was staff in-serviced on equipment? How long ago? How frequently is
the equipment used? Were alarms, displays, and controls identifiable and/or operating properly? Is the
equipment set up and performing in accordance with the manufacturer’s recommendations? Were there
equipment recalls that were not addressed? Was equipment designed to accomplish its intended purpose?
Were equipment parts defective? Was there a report to another agency regarding equipment defect (FDA,
etc)?
No equipment issues were involved in this event.
What controllable factors directly affected the outcome?
Identify factors that may have contributed to the event that the organization has the ability to change by
making process improvement changes.
Were there uncontrollable external factors?
Uncontrollable external factors are those factors that the organization cannot change that contribute to a
breakdown in internal processes. An organization should not be willing to assign many issues to this
category. Although a factor may be beyond the organization’s control, the organization may be able to
minimize the factor’s effect on patients.
Father coming to see daughter (not under organization’s control)
What other areas or services are impacted?
List all other areas that have the potential for a similar event to occur. This will assist in implementing risk
reduction strategies in other pertinent high-risk areas.
Inpatient units
Any ancillary/clinical department that may separate parent from pediatric patient
To what degree is staff properly qualified and currently competent for their
responsibilities?
Include all staff present, not just those that were determined to be involved with the event. Do not overlook
physicians and allied health practitioners/mid-levels. Determine if staff was formally trained to perform the
specific duties or tasks involved in the event. Was the training adequate? Was staff qualified to use the
equipment? Were competencies documented? Had procedures and equipment been reviewed to ensure a
good match between people and tasks performed? Was there agency staff that may not have been familiar
with procedures/equipment? Was float staff from another area assisting with lack of orientation to the unit
they floated to? Was the individual new and performing a function that they were not
oriented/trained/competent in performing? Was staff oriented to the organization and department specific
policies/procedures?
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statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.
No process in place at the time of incident to provide guidance to staff to directly prevent such an
incident
Staff had been appropriately oriented to the department/organization and did not have any
performance issues.
How did actual staffing compare with ideal levels?
Was there appropriate staffing at the time of the event to address the required workload? Keep in mind if it
was a weekend, change of shift, holiday, break time. Document the actual staffing in area of occurrence
versus planned staffing according to the staffing model. Explain any variation; higher or lower staffing.
Pre-op: Staffing model requires four RNs and one unit secretary that is shared with post-op side.
Actual staffing was three RNs which resulted in pre-op nurses prepping additional patients than
usual.
Post-op: Staffing model requires four RNs with the shared unit secretary. Actual staffing was
three RNs.
What are the plans for dealing with contingencies? What would reduce effective
staffing levels?
Summarize current plans in place to deal with staffing deficiencies.
Plans are in place to use float pool nurses, contact part-time staff for extra hours, or reassign staff
from other units.
How has staff performance in the relevant processes been assessed? When was this last
performed?
Consider staff performance relative to the specific processes associated with the event.
NA—No process in place at the time of incident to provide guidance to staff to directly prevent
such an incident
How can orientation and in-service training be improved?
Was all staff oriented to the job responsibilities, organization, and policies and procedures regarding safety,
security, hazardous materials, emergency, equipment, life-safety, treatments, and procedures? Are policies
revised/updated, evidence based, and readily available? Have policies or procedures changed without
providing additional training? Was a new policy developed and staff training conducted? Do float staff or
agency staff receive training within the areas they are assigned? Is this documented?
To what degree is all information available when needed?
Was information from various patient assessments completed, shared, and accessed by members of the
treatment team as required by policy? Was the patient correctly identified? Was the documentation clear
and did it provide an adequate summary of the patient’s condition, treatment, and response to treatment?
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statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.
Was the level of automation appropriate? Identify what information systems were utilized during patient
care.
To what degree is communication among participants adequate?
Look at this content to cover verbal and lack of verbal/written communication(s).
Physician to….
Nurse to….
Tech to….
Pharmacist to….
Hierarchical issues….
Cultural issues….
And any other combination you can find during your investigation.
To what degree was the physical environment appropriate for the processes being
carried out?
Look closely at the environment the patient was in or was transferred to/from. Spaces, privacy, safety, and
ease of access are a few items to consider. Was work performed under adverse conditions (hot, humid,
improper lighting, cramped, noise, construction projects)? Had there been environmental risk assessments
conducted? Did the work environment meet current codes, specifications, and regulations? Was the work
environment appropriate to support the function it was being used for?
NA—Physical environment did not play role in incident
What emergency and failure mode responses have been planned and tested?
Had appropriate safety evaluations and disaster drills been conducted? Had provisions been planned and
available to support a breakdown in operations?
“Code Pink” drills are done sporadically and not on routine basis
To what degree is the culture conducive to risk identification and reduction?
Did the overall culture of the facility encourage or welcome change, suggestions, and warnings from staff
regarding risky situations or problematic areas? Does management establish methods to identify areas of risk
or access employee suggestions for change? Are changes implemented in a timely manner?
A member of the Senior Leadership group, including the CEO, participates in meetings related to
serious adverse events.
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statute. It is not to be distributed outside the quality assurance, performance improvement, peer review process.
Senior Leadership and department management encourage staff to bring opportunities and
suggestions forward that would improve patient care and the work environment.
Senior leadership and department management all are active in patient safety rounds and
encourage open discussion of patient safety issues among staff.
What are the barriers to communication of potential risk factors?
What is your organization doing to break down barriers to effect change? Has the organization identified
barriers to effective communication among caregivers? If there are no barriers, what have you done and how
do you know it has been successful? Be specific.
To what degree is the prevention of adverse outcomes communicated as a high priority?
Explain leadership’s role and how it is put into practice, provide examples.
A confidential suggestion box and hotline have been established to report high-risk issues and
each of these are read and evaluated by the Patient Safety Officer. Corrective actions are taken
on a regular basis.
“Patient Safety” is one of the organization’s values.
Was there a literature search done?
List all sources of literature accessed to complete the analysis and action plan. Literature may be accessed to
assist in analyzing the event to determine process breakdowns and/or when developing actions once the root
causes have been identified to assist in developing best practice recommendations for changing current
practice.
NA
Accreditation Audit Case Study – Task 2 Artifacts/Sentinel Event Interview.swf
Accreditation Audit Case Study – Task 2 Artifacts/Sentinel Event Report.pdf
Sentinel Event Report
The pre-op nurse told the mother that once Tina went to the OR, her surgery would take about 45 minutes and
then she would go to recovery and she would be there at least one hour. The mother told the nurse that once
Tina went to the OR, she needed to run a quick errand involving an older sibling and would return in time to pick
her up once she got out of recovery. The mother gave the pre-op nurse her cell phone number with instructions
to contact her if Tina got out of surgery sooner than expected.
Tina’s mother returned to pick her approximately 2 ½ hours later and found that Tina was discharged 30 minutes
earlier.
Tina’s mother was extremely distraught, security was called, and a “Code Pink” (hospital-wide child abduction
alert) was activated. Local law enforcement was also contacted by hospital security. When the security officer
interviewed the mother, she shared with him that she and Tina’s father were divorced and that she had full
custody of Tina and her siblings.
Tina was located within 30 minutes of her mother’s arrival, by local law enforcement, in the care of her father. He
had taken her to his home to await the arrival of the mother.
No charges were filed against the father. The CEO of Nightingale Memorial Hospital assured Tina’s mother that
this incident would be analyzed and processes put into place to prevent this type of event from recurring.
