Sentinel Events
This event involves a patient falling and sustaining a major injury.
What is a fall resulting in major injury?
Sentinel event definition
What is an unexpected occurrence involving death, serious physical injury, or risk thereof?
A culture that promotes learning and accountability rather than blame.
What is Just Culture?
This HRO principle means constantly looking for small signs that something could go wrong.
What is Preoccupation with Failure?
8 hours
What is the time frame that our area manager has to report a sentinel event to his regional leadership?
A retained surgical item discovered after surgery is an example of this type of event.
What is a sentinel event?
Define a "near miss.
What is an an event that could have caused harm but did not
This is the primary goal when reviewing most human errors.
What is learning and system improvement?
This HRO principle encourages staff to avoid oversimplifying explanations for errors.
Reluctance to Simplify
A nurse accidentally administers a medication late because two medications had nearly identical packaging. The event is reported, analyzed, and leads to changes in storage and labeling. This approach reflects both this safety culture model and the HRO principle of learning from small failures.
What is Just Culture?
This accrediting body requires organizations to investigate sentinel events through a root cause analysis.
What is The Joint Commission?
A systematic process used to proactively identify and evaluate potential failures in a process before they occur.
What is Failure Mode and Effects Analysis (FMEA)?
Staff should feel comfortable reporting errors and near misses without fear of this.
What is punishment or blame?
This HRO principle focuses on awareness of frontline operations and current conditions
What is Sensitivity to Operations?
This accrediting organization identifies wrong-patient surgery, retained foreign objects, and patient suicide as examples of sentinel events.
What is The Joint Commission?
A patient receives surgery on the wrong body part. What type of event is this?
What is a sentinel event (wrong-site surgery)?
Define "adverse event."
What is an injury caused by medical management rather than the underlying condition?
This type of behavior involves an unintentional action, slip, lapse, or mistake.
What is Human Error?
This HRO principle involves the ability to adapt and recover when unexpected situations occur.
Commitment to Resilience
This state agency licenses and surveys hospitals in California.
What is CDPH?
What analysis method is commonly used to identify system causes following a sentinel event?
What is a Root Cause Analysis (RCA)?
Explain the difference between a near miss and an adverse event.
What is a near miss does not reach the patient or cause harm; an adverse event reaches the patient and causes or has the potential to cause harm?
Disciplinary action is most appropriate for this type of behavior.
What is Reckless Behavior?
This HRO principle recognizes that people with the most expertise should influence decisions, regardless of rank.
What is deference to Expertise?
Another regulatory agency, besides the TJC that accredits hospitals and integrates quality management standards with Medicare Conditions of Participation.
What is DNV?