Sentinel Event AssignmentFill out the worksheet I have attached based on the following scenario: John Williams a 44-year-old patient who arrives in the ED complaining of a terrible headache. He has a blindfold on to shield all light in an attempt to reduce his pain currently reported to be 9/10. After a quick assessment the physician orders the patient to receive oral pain medication. • The order reads Norco 7.5 mg – 325 mg two tablets every 4 hours prn moderate pain (6-8/10). Nurse Judy retrieves the medicine and takes it to the bedside where she has difficulty scanning the medication’s barcode but the patient is moaning and grabbing his head so she overrides the scanner and administers the medication. Later the supervisor asks Nurse Judy why the narcotic count is wrong for Norco 10mg-325mg. After an investigation it is determined that Mr. Williams received a larger dose than was ordered. When Nurse Judy left for the day she met her carpool driver in the elevator who asked her how her day went. The elevator was crowded and Judy was daydreaming but blurted out “my supervisor got all bent out of shape because I gave Mr. Williams the wrong dose for his pain pill. I am sure he did not mind since he went to sleep and stopped moaning. Can you imagine coming to the ED for a headache?” SAMPLE Event Types (Each type has sub ‘categories’): Admission/Discharge/transfer Maternal/Childbirth/Newborn Behavior Medical Records/ Documentation Blood and Blood Products Medication /ADR Care Management/Care Coordinator Nutrition/ Dietary Devices/ Medical Equipment/Supplies Patient Protection Diagnosis/ Assessments Pre-operative – No patient Involved Environment Radiology Events Fall Safety/Security/Privacy/Conduct Fall(visitor) Skin Integrity Infection prevention Surgery and Invasive Procedures Laboratory Events Treatment/Therapy/Procedure Complete the event report as soon as possible once the patient has been assessed/stabilized and physician notified. • Documentation should be concise objective and focused • The report’s existence should NOT be noted in the medical record • No copy of the incident report will be placed in the medical record or scanned into the EMR • Minimally include the following details about the event: o Date and time o Affected individual(s) o Location o Actual vs Near-Miss o Narrative description (brief/concise) o Category (Medication/Fall/Surgical/etc) o Notification of physician (name and date/time) o Witness name(s) o Related outcomes and/or consequences o Actions taken immediately post-event? o Contributing factors if any identified Event Reporting Checklist • When did the event occur? Record the date and time. • Who was the affected party? Select from Patient Employee or Visitor. • Department where the event occurred. Any other departments and/or facilities involved? • Was this an actual or near miss event? • What happened? Briefly describe the event. • Choose a safety event category. Review the options displayed and select the best fit. For example: ➢ Medication related event? ➢ Fall/Slip? (observed/unobserved) ➢ Treatment-related? ➢ Surgery-Related? (wrong patient? Wrong procedure?) • What is the event severity category? • Was a physician notified? • Did anyone witness the event? • List any outcomes and consequences related to the event. What was the effect of the event on the affected party? • Any actions taken immediately after the event? • Any contributing factors that could have led to the event?
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