discussion

Week 2 - Discussion Forum

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Your initial discussion thread is due on Day 3 (Thursday) and you have until Day 7 (Monday) to respond to your classmates. Your grade will reflect both the quality of your initial post and the depth of your responses. Refer to the Discussion Forum Grading Rubric under the Settings icon above for guidance on how your discussion will be evaluated.

Sentinel Event [WLOs: 1, 2] [CLOs: 1, 2, 3, 5]

Prior to beginning work on this discussion, read through the following webpages and resources to understand the purpose of documenting sentinel events as well as methods and reporting requirements:

· Sentinel Event Policy and Procedures (Links to an external site.)

· PSNet Search (Links to an external site.)

· Sentinel Events Download Sentinel Events

· Sentinel Events (SE) (Links to an external site.)

· Topic 6: Understanding and Managing Clinical Risk (Links to an external site.)

Your initial discussion post must be a minimum of 250 words. All referenced materials must include citations and references in APA format. Please see directions for including APA Style elements on these Writing Center pages: APA: Citing Within Your Paper (Links to an external site.) and Formatting Your References List (Links to an external site.).

Sentinel events occur in nearly all health care organizations. According to the Maine Department of Human Services,

facilities that are vigilant about identifying and reporting errors…foster an organizational culture where staff members feel comfortable reporting patient safety concerns without fear of reprisal. Healthcare facilities that embrace this safety-focused culture look at adverse events as opportunities to learn and improve. (2018, p. 5)

You are assigned a sentinel event topic based on the first initial of your last name (see table below). Based on your assigned topic, research a sentinel event, or create your own scenario. You will use this sentinel event for other assignments later in class.

Operation/post-operation complication events

From a health care provider perspective (e.g., hospital, physician’s practice, long-term care, hospice, home health, surgery center, etc.), write a brief description of the sentinel event in your own words.

In addition, address the following:

· Identify the sentinel event, who was involved, what occurred, and where it occurred.

· Describe the applicable accrediting agency’s requirements for reporting the event (e.g., OSHA, ACHA, CMS, CDC, CLIA, The Joint Commission [TJC], AHCA, state agencies).

· Discuss the probable cause that may have contributed to the sentinel event (e.g., process failure, human error, policy error, systems error, technology failure, etc.).

· Create a recommendation that will reduce the risk of future events from occurring.

Guided Response: By the end of Day 7, review your classmates’ posts and respond to two of your fellow classmates. Choose two different topics from the one you were assigned. Recommend one quality improvement process that you would put into place to avoid future occurrences and explain its use. Your responses to your classmates should be substantive and a minimum of 100 words.

Reference

Department of Health and Human Services, Division of Licensing and Certification. (2018). Sentinel events CY2018: Annual report to the Maine State Legislature (Links to an external site.) [Report]. https://www.maine.gov/dhhs/dlc/medical-facilities/sentinelevents/documents/Sentinel-Event-Annual-Report-2018-3-19.pdf