Sentinel Event Fall

Sentinel Event Fall
For this written assignment, you will prepare an executive summary for the CEO using the same sentinel event addressed earlier in the course. This report will be prepared for the CEO of the organization where the sentinel event occurred. The CEO is then required to provide details from the executive summary to the Board of Trustees and other stakeholders in the organization to identify the next steps of managing the sentinel event.
Managing a sentinel event usually consists of the following steps: immediate action, planning the investigation, data collection, data analysis, corrective action plan, and reporting to accreditation agencies.focus on the parts below to develop a cohesive plan to address the sentinel event. Address the following in the Executive Summary to CEO template Download Executive Summary to CEO template.
Part 1: The Sentinel Event
Summarize the facts related to the sentinel event:
o Description of the event
o Staff involved
Discuss the timeline events from initiation of the error through the resolution (will vary depending upon the sentinel event):
o When and/or where did the error occur?
o When was it detected?
o When was it reported and to whom?
Evaluate procedural errors:
o Identify the point in time when the error should have been detected before it occurred.
o What part of the process or procedure was missed that contributed to the sentinel event?
Analyze accreditation agency (e.g., OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA, state agencies) requirements:
o Identify which agency(s) would be involved
o Define the agencys purpose
o Discuss the agencys reporting expectations based on the incident
Part 2: Root Cause Analysis: Fishbone Diagram
Create a fishbone diagram Download fishbone diagram. You will be responsible for creating the CQI Tool (fishbone), completing the tool, copying or taking a screenshot of the completed work, and pasting the completed fishbone diagram into the final document.
o If you are unfamiliar with the fishbone, please refer to the Using Quality Improvement Methods for Evaluating Health CareLinks to an external site. article by Siriwardena (2009).
o In addition, as a learning resource, the CQI tool listed below is hyperlinked to the Institute for Health Care Improvement website, which discusses and illustrates an example of the Fishbone. Tools: Cause and Effect DiagramLinks to an external site.
Part 3: Root Cause Analysis Report
Create a root cause analysis.
o Identify the data you would collect to determine the cause.
o Give your rationale for choosing the data.
o Identify the probable cause, which may include a process failure, human error, cultural biases, policy error, systems error, technology failure, etc., that may have contributed to the sentinel event. Consider the following as applicable to your chosen event as you complete this segment:
What human factors were relevant to the outcome?
What process errors were relevant to the outcome?
Were there any steps in the process that did not occur as intended?
How did the equipment performance affect the outcome?
What are the other areas in the health care organization where this could happen?
Did staff performance during the event meet the expectations?
Develop a corrective action plan that is geared towards eliminating future events.
o Explain the steps of implementing the corrective action plan. Consider the following in developing your response to this component:
Identify risk reduction strategies
Improvement of processes or systems
Communication barriersfor example, discuss the communication breakdown that might have contributed to the sentinel event, or what barriers may have occurred to cause the breakdown in communication (e.g., residual intimidation, reluctance to report a coworker, missing information at time of transition of care, etc.).
Training (e.g., orientation, professional development, cultural competency, skills training, in-service)
Equipment (e.g., technology, maintenance, and updates)
Policies and procedures (e.g., new or revised)
Describe the monitoring process that will be used to evaluate the success of the corrective action plan.
Analyze the components that may require the reallocation of budgetary resources. Consider the following as applicable to your sentinel event:
o Legal action
o Public relations (reputation leading to decreased revenue)
o Equipment and supplies
o Training and education
o Patient-centered communication methods (e.g., informed consent, procedural education, patient involvement [identify or mark the location of the surgical site])
o Staffing (e.g., reallocating staff, role responsibilities, hiring temporary or permanent staff)
Paper requirements:
The Executive Summary to CEO capstone assignment
Must be a minimum of 8 double-spaced pages in length (not including title and references page must include an introduction and conclusion paragraph. Your introduction paragraph needs to end with a clear thesis statement that indicates the purpose of your paper must use at least eight credible published within the past ten years.

Sentinel Event Fall Related Events
A sentinel event occurs when a patient dies or is seriously injured due to medical care unrelated to their illness. This includes delayed treatment, drug mistakes, fires, foreign object retention, and falls. In my discussion, I will discuss fall-related events, what causes and consequences of falls, and my advice for avoiding similar incidents in the future.
Despite several precautions, the number of falls has been rising over time. Weak leg muscles, disorientation, loss of consciousness, and bumping into hospital furniture are all potential causes (Blaeviien et al.,2020). Patient falls resulting in harm are frequently reviewed sentinel vents by The Joint Commission.

Sentinel Event Fall
The patient suffered multiple falls in 2019 and ultimately passed away at the local Hospital. One of the nurses discovered him bleeding from the scalp after falling to the ground. The 78-year-old man’s death was caused by a subdural hematoma and an ischemic frontal lobe stroke, even though he had diabetes.
Requirements for reporting
When a patient falls, the caregiver must stay with them and call for help (Abraham et al., 2022). Assess the patient’s heart rate and blood pressure. Call the Hospital’s emergency number and begin CPR if the patient is unresponsive, not breathing, and has no pulse. TJC recommended checking vitals and doing a comprehensive checkup before transporting the patient.
Causes of the event
He was believed to be in danger of falling, yet, his death was caused in part by a lack of nurses who could have provided closer monitoring and care, as well as by the absence of safety measures designed to prevent such falls (LeLaurin & Shorr, 2019).
Recommendation
I suggest hospitals single out those with a higher risk of falling for specialized attention. More nurses should be hired, and volunteers should be encouraged so that hospital patients can get help whenever they need it. Facilities that identify and report errors to increase patient safety are focused on opportunities to learn and improve.
References
Abraham, J., Hirt, J., Richter, C., Kpke, S., Meyer, G., & Mhler, R. (2022). Interventions for preventing and reducing the use of physical restraints of older people in general hospital settings. Cochrane database of systematic reviews, (8).
Blaeviien, A., Laurs, L., & Newland, J. A. (2020). Attitudes of registered nurses about the endoflife care in multi-profile hospitals: A cross-sectional survey. BMC palliative care, 19(1), 1-8.
LeLaurin, J. H., & Shorr, R. I. (2019). Preventing falls in hospitalized patients: state of the science. Clinics in geriatric medicine, 35(2), 273283.

Last Completed Projects