Joint Commission Case Study
Joint Commission. (2017). The Joint Commission. Topics Library: Sentinel Events Policy and Procedures. Retrieve from https://www.jointcommission.org/sentinel_event_policy_and_procedures/
Joint Commission describes a sentinel event as Patient Safety Event that affects the patient by death, permanent harm, severe temporary harm with required intervention to sustain life, suicide of any patient receiving care, treatment, or services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the organization’s emergency department (ED), unanticipated death of a full-term infant, discharge of an infant to the wrong family, abduction of any patient receiving care, treatment, or services. Such events are termed sentinel because of the need for immediate investigation and response.
Perry, M. C. (2006). A Fish(bone) Tale. Quality Progress, 39(11), 88. Retrieved from https://wgu.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=asf&AN=501333980&site=eds-live&scope=site
The fishbone diagram is a quality improvement tool developed by Kaoru Ishikawa to help identify potential …show more content…
Effective and efficient communication is necessary to eliminate the consequences of communication errors. A standardized tool, situation-background-assessment-recommendation (SBAR), was created by the U.S. Navy as a means to reduce communication errors that could lead to adverse consequences. The tool is successful at standardizing communication, especially in high-stress settings. The use of the SBAR protocol in critical situations has been shown to increase communication among nurses. Moreover, the standardized protocol has been found to facilitate the development of process models that aid nurses in decision making. Furthermore, the study suggests that the SBAR protocol is more valuable than creating a structured communication
Joint Commission describes a sentinel event as Patient Safety Event that affects the patient by death, permanent harm, severe temporary harm with required intervention to sustain life, suicide of any patient receiving care, treatment, or services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the organization’s emergency department (ED), unanticipated death of a full-term infant, discharge of an infant to the wrong family, abduction of any patient receiving care, treatment, or services. Such events are termed sentinel because of the need for immediate investigation and response.
Perry, M. C. (2006). A Fish(bone) Tale. Quality Progress, 39(11), 88. Retrieved from https://wgu.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=asf&AN=501333980&site=eds-live&scope=site
The fishbone diagram is a quality improvement tool developed by Kaoru Ishikawa to help identify potential …show more content…
Effective and efficient communication is necessary to eliminate the consequences of communication errors. A standardized tool, situation-background-assessment-recommendation (SBAR), was created by the U.S. Navy as a means to reduce communication errors that could lead to adverse consequences. The tool is successful at standardizing communication, especially in high-stress settings. The use of the SBAR protocol in critical situations has been shown to increase communication among nurses. Moreover, the standardized protocol has been found to facilitate the development of process models that aid nurses in decision making. Furthermore, the study suggests that the SBAR protocol is more valuable than creating a structured communication