The Sentinel Event and the Root Cause Analysis Using Fishbone Diagram

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. *** MUST USE TEMPLATE PROVIDED. TO RETRIEVE TEMPLATE FOLLOW LINK BELOW.
https://ashford(dot)instructure(dot)com/courses/78376/files/14543026/download?wrap=1
Part 1: The Sentinel Event
Summarize the facts related to the sentinel event:
Description of the event
Staff involved
Discuss the timeline events from initiation of the error through the resolution (will vary depending upon the sentinel event):
When and/or where did the error occur?
When was it detected?
When was it reported and to whom?
Evaluate procedural errors:
Identify the point in time when the error should have been detected before it occurred.
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:
Identify which agency(s) would be involved
Define the agency’s purpose
Discuss the agency’s reporting expectations based on the incident
Part 2: Root Cause Analysis: Fishbone Diagram
Create a 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.
**** FISHBONE DIAGRAM EXAMPLE
https://ashford(dot)instructure(dot)com/courses/78376/files/14542974/download?wrap=1
Part 3: Root Cause Analysis Report
Create a root cause analysis.
Identify the data you would collect to determine the cause.
Give your rationale for choosing the data.
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.
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 barriers—for 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:
Legal action
Public relations (reputation leading to decreased revenue)
Equipment and supplies
Training and education
Patient-centered communication methods (e.g., informed consent, procedural education, patient involvement [identify or mark the location of the surgical site])
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 10 double-spaced pages in length (not including title and references pages) and formatted according to APA Style
*** MUST USE TEMPLATE PROVIDED. TO RETRIEVE TEMPLATE FOLLOW LINK BELOW.
https://ashford(dot)instructure(dot)com/courses/78376/files/14543026/download?wrap=1
Must include a separate title page with the following:
Title of paper
Student’s name
Ashford University
Course name and number
Instructor’s name
Date submitted
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 sources.
Must include a separate references page in APA Format
*** MUST USE TEMPLATE PROVIDED. TO RETRIEVE TEMPLATE FOLLOW LINK BELOW.
https://ashford(dot)instructure(dot)com/courses/78376/files/14543026/download?wrap=1
PLEASE USE THE FOLLOWING SENTINEL EVENT:
Almost 15 years ago, my grandad was diagnosed with Stage 4 Colon cancer and Alzheimer’s disease. He had been in and out of the hospitals for treatment and it wasn’t much that the doctors could do. He was eventually admitted to a nursing home facility for 24 hour care. Since he had Alzheimer’s he would wander off during the night. One night he woke up and attempted to leave the nursing home. He ended up falling and the nurses didn’t find him until the next day.
TIME: 0300 August 29, 2006
PLACE: Shreveport Medical Nursing Facility
WHAT: Patient fell out of the bed as he attempted to leave the nursing facility
PATIENTS NAME: Herman Armstrong
AGE: 65