Slide 1

Slide 2 Slide 3 Dr. Sheryl Cornelius, EdD, MSN, RN Slide 4 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. Slide 5 The need to improve care The need to maintain quality care The need to continue to improve quality within the organization Slide 6 Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System 98,000 deaths in hospitals each year Current system fragmented and poorly organized Committee on the Quality of Health Care in America Crossing the Quality Chasm Chronic diseases now leading cause of illness, disability, health problems Current system complex, fragmented, disorganized Slide 7 Observing any problems Notifying the proper personnel Taking part in pilot studies the facility may undertake Slide 8 Sentinel Event an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Never Event extremely rare medical errors that should never happen to a patient Slide 9 Slide 10 What 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/ Slide 11 Change 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 Slide 12 Find an example online and discuss how the facility handled it Slide 13 The 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 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 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/ http://www.jointcommission.org/ Slide 14 North 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. (6 th ed.). Philadelphia : Lippincott, Williams & Wilkins. Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals of Nursing: The Art & Science of Nursing Care. (7 th ed.) Philadelphia, Lippincott, Williams & Wilkins.