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Accreditation Audit Essay

2823 words - 12 pages

RAFT –Task 2 Root Cause Analysis A-1. Sentinel Event A sentinel event is an event that happens expectantly in a healthcare facility that could result possible death, physical or mental injury to patients unrelated to natural causes of the patients illness as defined by Joint Commission (www.joint On the afternoon of Thursday, September 14, at approximately 12:30 p.m. a ‘Code Pink’ (child abduction alert) was called when a minor child/patient, Tina, was discharged to the care of her father without the knowledge of her mother with whom she was admitted with. Tina was registered into the hospital system by Katie Jessup, hospital registrar, who entered all proper demographics ...view middle of the document...

Tina was located by local law enforcement within a half hour her arrival at the hospital. Tina was unharmed and in the care of her father. He had taken her to his home waiting to hear from her mother. No charges were filed. Tina’s mother was informed by Nightingale’s CEO that the matter would be investigated to prevent this type of error from reoccurring.

A-2. Personnel According to my own hospital experience, I referred to East Jefferson General Hospital’s definition to the following positions filled in a hospital: Registrar—the position of a registrar is that they are the first point of contact during the admission phase. The registrar’s duties include, the collection of patient information, valid identification, verifying insurance information, making copies of said information. The registrar also inputs patient information into a computer system and verify necessary physician referrals and insurance authorizations. Also they are responsible for assigning bed, and carry out procedures to admit, transfer or discharge patients. In addition, the registrar is usually the first person seen in the admission process therefore other administrative duties may be required. The registrar also explains financial responsibility to the patient and also process payments, such as co-pays and bills due ( During the sentinel event the patient registrar carried out all duties specified above, however she did not ask for proper identification nor did she ask if Tina’s mother was the custodial parent. Surgeon—responsibilities include consultations with colleagues, patients, and patient families. The surgeon is held accountable to conduct evaluations on patient’s illnesses. In addition, the surgeon is responsible for preforming the surgery and/or initiating a referral. He is accountable to counsel and advise patients. In conclusion, the surgeon is responsible for accurately documenting a patients chart and inspecting and monitoring area of incision ( During the sentinel event the role of the surgeon was carried out without any mishaps however his office did not forward custodial information which may have prevented this error. It is not his job to do this, however, information pertinent to the patient should be made available to the hospital. Chief Nursing Officer (CNO)—is in charge of the entire nursing staff at hospitals and hospital institutes. CNO’s are responsible for the management of nurses in their department by providing feedback, training, support, and disciplinary actions when called for. CNO’s are also accountable for the development of programs and procedures that will help the hospital institutions run efficiently and promote growth ( The role of the CNO was that of an ineffective leader in that she was unavailable (why?) when the incident occurred, however she took responsibility and accountability.

Pre-op Nurse—is responsible for working closely with the attending surgeon. Her list of...

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