NRSG 314 Unit 4 – Discussion Board SOLUTION

NRSG 314 Unit 4 – Discussion Board SOLUTION

NRSG 314 Unit 4 – Discussion Board SOLUTION

Sentinel Policies and Procedures

My health facility is accredited by the Joint Commission and thus, it follows the regulations and standards set by the agency and other regulatory bodies. For instance, the health organization has its own sentinel policy and procedures that define sentinel events and outlines the steps to take when such an event occurs. The first item in the organization’s policy is reporting sentinel events. The Joint Commission requires health facilities to report such events; however, it is not mandatory (The Joint Commission, 2022). Secondly, when an event occurs, the policy recommends that a team consisting of a physician, charge nurse, and other appointed practitioners respond to the patient to stabilize the situation and provide a report. The team should also inform the patient and his/her and provide the necessary support, which is consistent with the regulatory requirements of The Joint Commission. Similarly, the organization outlines the procedure for conducting analysis and reporting the event to the Joint Commission as per the agency’s requirements. Another element of the policy consistent with the regulations of the Joint Commission is developing an action plan to prevent future occurrences.

Importance of Regulation by Agencies

The regulating agencies such as the Joint Commission have an important role in providing standards, policies and procedures, which ensures that organizations maintain safety and quality standards. Through these policies and procedures, the Joint Commission supports organizations to implement quality improvement and patient safety measures, contributing to care excellence (Inomata et al., 2018). The strategies provided by the Joint Commission help organizations to maintain continuous quality improvement, which in return reduces the risk of errors or underperformance (Ibrahim et al., 2022). Ultimately, organizations manage to attain and continue to improve quality measures used to measure the performance quality of a health organization and required for reimbursement purposes.

NRSG 314 Unit 4 – Discussion Board SOLUTION References

Ibrahim, S., Reynolds, K., Poon, E., & Alam, M. (2022). The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ, 377:e063064. https://doi.10.1136/bmj-2020-063064.

Inomata, T., Mizuno, J., Iwagami, M., Kawasaki, S., Shimada, A., Inada, E., . . . Amano, A. (2018). The impact of Joint Commission International accreditation on time periods in the operating room: A retrospective observational study. PLoS One. , 13(9),e0204301. https://doi.10.1371/journal.pone.0204301.

The Joint Commission . (2022). Sentinel Event Policy and Procedures. Retrieved from The Joint Commission: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-policy-and-procedures/

Responses to Other Students: Respond to at least 2 of your fellow classmates with at least a 100-word reply about their Primary Task Response regarding items you found to be compelling and enlightening. To help you with your discussion, please consider the following questions:

• What did you learn from your classmate’s posting?
• What additional questions do you have after reading the posting?
• What clarification do you need regarding the posting?
• What differences or similarities do you see between your posting and other classmates’ postings?

According to The Joint Commission, a sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm and intervention required to sustain life (The Joint Commission, 2022). Accredited health care organizations are not required but are strongly encouraged to report sentinel events to The Joint Commission. If a sentinel event occurred, The Joint Commission is requesting the healthcare organization to prepare a comprehensive analysis the root cause of the event, and a corrective action plan.

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          As an employee working at a Kaiser Permanente urgent care department, I have learned that Kaiser promoted the culture of reporting medical errors in a blame-free environment with the intent to identify flaws in the system, to identify the root or systemic cause of error and to find strategies to create a safer patient environment by implementing interventions to reduce the likelihood of similar events occurring in the future. Similar to the Joint Commission, Kaiser promotes transparency by encouraging staff to report medical errors without blaming or finger-pointing.  In addition, Kaiser has policies and procedures in place to provide internal quality control measures. According to the article “Kaiser Permanente’s Response to JCAHO’s Sentinel Event Standards: Our Significant Event Root-Cause Analysis Program Leads to Preventing Medical Errors”, Stajer and Pate write: “Quality and risk management committees routinely examine unexpected deaths and errors and monitor patient issues” and “Root-cause analysis with in-depth analysis done to identify the root or ultimate systematic cause of errors” (Stajer & Pate, 2000).

Policies and procedures set by the Joint Commission and other regulating agencies are important as their purpose is to protect the patients, improve the system and prevent further harm.  It is one the means to improve patient safety and prevent future adverse events as well. By encouraging healthcare organizations to report sentinel events and provide a comprehensive analysis of the root cause of the event and a corrective action plan, healthcare organizations can help to prevent recurrence of similar events to prevent harm and danger to patients.  Without policies, procedures and regulations, healthcare organizations may not report all sentinel or adverse events.  As Sherwood and Barnsteiner stated, unreported events will not improve patient safety as we cannot learn from the events and therefore would now know how to prevent future adverse events and to improve patient safety (Sherwood & Barnsteiner, 2021).

NRSG 314 Unit 4 – Discussion Board SOLUTION References

Sentinel event policy and procedures. (2022). The Joint Commission. https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-policy-and-procedures/

Sherwood, G., & Barnsteiner, J. (2021). Quality and Safety in Nursing (3rd Edition). Wiley Global Research (STMS). https://coloradotech.vitalsource.com/books/9781119684459

Stajer, R., Pate, B. (2000, June 1). Kaiser Permanent’s response to JCAHO’s sentinel event standards: our significant event root-cause analysis program leads to preventing medical errors. The Permanente Journal, 4(2), 117-123. https://doi.org/10.7812/TPP/00.962

Sentinel events are reported through Unusual Occurrence Reports (UOR) at the facility I work in.  There is a process that is followed.  When an event occurs that causes injury or can cause injury it is submitted to a database that is tracked region wide.  An investigation is then started. This is where a root cause analysis is implemented.  The people involved are interviewed in a blame free environment.  The focus is on the why the mistake happened not who made the mistake.  It is reported to JCAHO and this is when steps to figure out how to improve or prevent the problem will begin.  There will be a plan on how the problem will be resolved and an action which is usually education of staff.  Our facility follows the Joint Commission’s regulations regarding Sentinel event reporting.  The goal is to find a way to improve and keep patient’s safe (Reijmerink, 2022).

It is important for the Joint Commission or other regulating agencies to provide policies and procedures in order to hold the facilities accountable on providing safe medical care with the focus on patient safety.  When the facilities are accredited, they have a responsibility to provide quality, safe and continue to improve healthcare.  They ensure a quality improvement process is provided and this process has to be data driven in order for results to be of quality.  This ensures the public that the organization will meet and exceed high standards of care for the patients (Pullen, 2022).

Pullen, Richard L. Jr. EdD, MSN, RN, CMSRN, CNE-cl, ANEF. The importance of accreditation. Nursing Made Incredibly Easy!: May/June 2022 –               Volume 20 – Issue 3 – p 47-48. doi: 10.1097/01.NME.0000824636.94923.af

Reijmerink, I. M., Bos, K., Leistikow, I. P., Groeneweg, J., Cnossen, F., Dongelmans, D. A., & van der Laan, M. J. (2022). Performance variability in            perioperative sentinel events: report on a nationwide data set. British Journal of Surgery, znac067.