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AccreditationAuditTask2-redone1.docxRunning head: ACCREDITATION AUDIT
ACCREDITATION AUDIT
Accreditation Audit Task 2
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Root Cause Analysis of Sentinel Event
Root Cause Analysis is one of the crucial element used to improve the performance of a given institution or group of people, mitigate harm and prevent future occurrence of adverse scenarios without blaming an individual person for the loss incurred. In the case study, the Sentinel examined through the Root Cause Analysis is the medical event. The Sentinel, in this case, involves an event in which a patient called Tina was missing in the hospital during her surgical operation period. The situation subjected Tina’s mother to psychological stress. Victim’s mother was concerned with her children and raised them alone without the assistance of her husband. Before the occurrence not the situation, Tina’s mother was supposed to run a quick errand that involved her elder daughter. The errand had to terminate on time because the surgical procedure was scheduled for exactly 45 minutes and the resting time was one hour.
Tina’s mother gave her contacts to the pre-op nurse to contact her in case Tina will get out of recovery before the provided time elapses. Tina’s mother came back to the hospital after two and a half hours. Tina had been discharged from the recovery room some thirty minutes ago when her mother arrived. Tina had been kidnapped from the hospital, therefore, Tina’s mother was traumatized and decided to raise an alarm for security assistance. The intervention of the security was effective because Tina was found in her father’s house. The CEO of the hospital gave an assurance to Tina’s mother that the incident will be analyzed for justice to be done.
Roles of the personnel
The people involved during this sentinel event included; pre-operation nurse, post-operation nurse, surgeon, and hospital secretary. These people had different responsibilities in this sentinel event. For instance, the pre-operation nurse was responsible for the setting Tina ready for surgical operation. The preparations done by the pre-operation nurse involved carrying Tina to the operation room, reassuring Tina about the procedure and checked for the physical signs presented by Tina. The Surgeon was responsible for examining Tina’s background before she proceeded to the operation providing appropriate treatment for Tina after completion of the physical observations and tests. The post-operation nurse was responsible for ensuring that the condition of Tina was good after the operation procedure, especially during the recovery time. The secretary in the event was involved in ensuring an effective and open communication between the patients, medical personnel and the clients like Tina’s mother. The secretary acted as a customer care unit and ensured that all stakeholders and clients in the facility are served according to their expectations. The cumulative responsibilities of this personnel were considered to improve patient experience and customer satisfaction.
Potential Barriers that Impeded Effective Interactions for Personnel Present
Many health facilities encounter various barriers during their daily operations. In this sentinel, the possible barriers that may have interfered with the effective interaction include failure to provide directions to the medical personnel concerning their responsibilities in the facility. Lack of effective communication is another barrier that may have contributed a lot to the occurrence of this sentinel event (Best, et al., 2012). There was poor communication between the staff who was responsible for attending to Tina and caring for the recovered. During the secretary and the registering unit should have questioned Tina’s mother about all relatives that may visit the facility. A wise medical personnel will ask if the girl has both parents or not. Tina’s mother would have mentioned about her divorce with the husband, therefore preventing the divorced father from accessing the recovery where Tina was. The staff was also not communicated and directed to perform their responsibilities. Lastly, poor communication is observed when Tina’s mother fails to provide the actual time she will take to come back from the errand. This delayed her from reaching the hospital on time. The failure of the pre-operation nurse to inform the post-operation nurse about the instructions provided by Tina’s mother is another main contributor to this mistake.
Ideas to Improve the Interactions among the Personnel
Interaction among all staff in the facility is important for realizing the goals of the hospital and improving patient satisfaction. Communication is a vital component in all forms of interactions (Krautscheid, 2008). A free communication among all medical staff should be maintained without intimidating the personality of the junior medical staff. The nurses should be able to communicate with each other and with other medical personnel in the facility, for example, the surgeon. All line of communication should be maintained in this health facility in so as to recognize the achievements and responsibilities of other people and groups regardless of their position. An open communication among the patients and health staff is always important because it limits the occurrence of mistakes that may arise the hospital.
Quality Improvement Tool / Root Cause Analysis
An appropriate tool that can be used to address this issue in the sentinel is continuous improvement of all the activities in the hospital. The management of the hospital led by the CEO should ensure that there is a change for improvement among all departmental groups in the facility. This technique will ensure that patients get appropriate medication and care from the health personnel (Prost, et al. 20130. There should be a change in the security group in the hospital because the event would have not occurred if they were keen on their responsibilities.
RM Program alterations to make the Sentinel Event does not happen again
The risk management program for this hospital should address all the weaknesses observed in the facility. The process change should be able to eliminate challenges that may be encountered from the application of continuous change strategy. This ensures that the sentinel event will not happen in the future. The process should involve training of all departmental staff and the security personnel on effective measures on how to improve their performance.
Available Resources
Root Cause Analysis is an effective resource that can be used to support the risk management program because the process involves a thorough examination of the possible weaknesses that need to be improved (Roebuck, et al., 2011). The application of the Root Cause Analysis will help in achieving continuous change and progress in the hospital.
Conclusion
An open communication among all whole groups is important because it ensures that all tasks are performed in an orderly manner. Communication is always important because it encourages free passage of information from one group to another. The sentinel event would have occurred if there was effective communication among all staff in the hospital.
References
Best, A., Greenhalgh, T., Lewis, S., Saul, J. E., Carroll, S., & Bitz, J. (2012). Large‐system transformation in health care: a realist review. The Milbank Quarterly, 90(3), 421-456.
Prost, A., Colbourn, T., Seward, N., Azad, K., Coomarasamy, A., Copas, A.,& MacArthur, C. (2013). Women's groups practicing participatory learning and action to improve maternal and new-born health in low-resource settings: a systematic review and meta-analysis. The Lancet, 381(9879), 1736-1746.
Krautscheid, L. C. (2008). Improving communication among healthcare providers: Preparing student nurses for practice. International Journal of Nursing Education Scholarship, 5(1), 1-13.
