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This presentation is intended to satisfy the exemplars Sentinel Events and Reporting under the concept of Quality Improvement in NUR 111 for the NC CIP Concept Based curriculum. Please see the corresponding case study that may be used with it.

1Quality ImprovementDr. Sheryl Cornelius, EdD, MSN, RN

Hello, I am Dr. Sheryl Cornelius, nursing faculty of Mitchell Community College in Statesville, NC

2Objectives:Upon completion of this module the student will be able to:Describe the role of the nurse in quality improvement. Outline what constitutes a sentinel event.Articulate reporting of a sentinel event.Analyze how sentinel events are associated with quality improvement.Describe the role of the nurse in reporting.

Our objectives for this module are as follows:3What is Quality Improvement? The need to improve care

The need to maintain quality care

The need to continue to improve quality within the organization

What is Quality improvement? QI is usually defined in 3 parts 1) the need to recognize things in your organization that are not working properly and improve upon them, 2) to maintain quality in the areas that have been improved upon, and 3) to continue that loop of constantly looking for more things that could be done better. It is a systems approach rather than an individual approach. Many facilities also call it Quality Assurance. It puts a positive spin on it saying that we know our product is already a good one but we want to continuously be striving to keep it that way or even better. 4Why do we need to improve?Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System98,000 deaths in hospitals each year Current system fragmented and poorly organized

Committee on the Quality of Health Care in AmericaCrossing the Quality ChasmChronic diseases now leading cause of illness, disability, health problemsCurrent system complex, fragmented, disorganized

The Institute of Medicine says we are not perfect, The Committee on the Quality of Healthcare in America says we are not perfect, and they have data to back it up. Healthcare as a whole has always known that they needed to work on things. This is the first time in history that we have published something for the public to read about how imperfect we are. In this day when the client has the right to choose physicians, choose hospitals, etc. it has become competitive to ensure your product is better than the rest. We also live in a society where we are quick to produce a lawsuit when things do not go perfectly. This fear of lawsuits has put even more emphasis on quality and even developed a newer department called Risk management. We will talk more about this later in the program. Links to these documents are provided in the further reading section at the end. 5What is the nurses role? Observing any problems

Notifying the proper personnel

Taking part in pilot studies the facility may undertake

I want you to get together in a few small groups and discuss what actually you will do as the nurse in the role of quality improvement. 6What is a Sentinel Event? Sentinel Event

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereofNever Event

extremely rare medical errors that should never happen to a patient

The Joint Commission implemented its Sentinel Event Policy in 1996. It would serve as a meaningful way to look at the terrible situation that needed immediate investigation and response. Accrediting agencies like TJC are expected to ensure implementation of a thorough and credible root cause analysis, implementation of improvements to reduce risk, and monitoring of the effectiveness of those improvements. Doni Haas, RN, director of risk management, described in 1998 her hospitals response to a medication error that caused the death of a 7-year-old boy: Every step in any process needs to be viewed as an opportunity for error. Opportunities for error are opportunities for improvement that must not be ignored. It does not matter how long a process has been the standard. Challenge it. (Taylor, )

In 2006, the National Quality Forum released a newly revised list of 28 events that they termed serious reportable events, extremely rare medical errors that should never happen to a patient. Often termed never events, these include errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreignobject inside a patient after surgery, or discharging an infant to the wrong person. By reporting and followingsuggested guidelines when a Never Event occurs, the likelihood of such an error happening again is greatlydecreased. Never Events are Sentinel Events but remember Sentinel Events are a TJC policy. 7Sentinel event

A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated. Events that fall into this category must be reported properly by leadership of the facility within 45 days. The percentages of reported events are in the picture above.8Root Cause AnalysisWhat happened?

Why did it happen?

What circumstances surrounded the event?

Framework for conducting a root cause analysis from TJC: http://www.jointcommission.org/Framework_for_Conducting_a_Root_Cause_Analysis_and_Action_Plan/

A root cause analysis is simply the framework to get to root of the problem. In getting to the root of the problem hopefully we can see where we went wrong, fix that step, and prevent the mistake from ever happening again. 9Role of the nurse in reportingChange the climate of reporting

Attend any briefings the facility may have on changes to your systems

Keep a hands on approach in the facility workings

The climate of the facility needs to be that reporting a problem is not punishment but simply making sure it does not happen again. Medication errors should not be looked at as failure on the part of the nurse but a mistake that could have been from the system and not the nurse. Nurses need to encourage a systems approach rather than a problem by one person. 10ActivityFind an example online and discuss how the facility handled it

Get into small groups and I want each of you to search for an evidenced based article on a sentinel event and how the facility handled it. Not an article about what it is but an example and how they handled it. 11Further readingsThe Institute of Medicine: To Err Is Human: Building a Safer Healthcare System http://www.iom.edu/Reports/1999/To-Err-is-Human-Building-A-Safer-Health-System.aspx The Institute of Medicine: Crossing the Quality Chasm http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx The Joint Commission: Read the Sentinel Event Alert under Topics tab http://www.jointcommission.org/

ReferencesNorth Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc.Marquis, B. L. & Huston, C. J. (2009). Leadership roles and management functions in nursing: Theory and application. (6th ed.). Philadelphia : Lippincott, Williams & Wilkins.Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals of Nursing: The Art & Science of Nursing Care. (7th ed.) Philadelphia, Lippincott, Williams & Wilkins.