NRSG 314 Unit 4 – Discussion Board
Primary Discussion Response is due by Thursday (11:59:59pm Central), Peer Responses are due by Saturday (11:59:59pm Central).
Primary Task Response: Within the Discussion Board area, write 250 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. You are required to use 1 scholarly resource, in addition to your textbook. Be substantive and clear, and use examples to reinforce your ideas.
Go to the Joint Commission Web site, and review sentinel event policy and procedures. Discuss the following:
- Review your clinical setting’s policy on sentinel events. How does it compare to the Joint Commission’s regulations?
- Why do you think it is important to have the Joint Commission or other regulating agencies provide policies and procedures?
Responses to Other Students: Respond to at least 2 of your fellow classmates with at least a 100-word reply about their Primary Task Response regarding items you found to be compelling and enlightening. To help you with your discussion, please consider the following questions:
- What did you learn from your classmate’s posting?
- What additional questions do you have after reading the posting?
- What clarification do you need regarding the posting?
- What differences or similarities do you see between your posting and other classmates’ postings?
Discussion Board Rubric
The Discussion Board Grading Rubric is a scoring tool that represents the performance expectations for the discussion. This grading rubric is divided into components that provide a clear description of what should be included within each component of the discussion. It is the road map that can help lead your discussion. Discussion Board Grading Rubric
For assistance with your assignment, please use your text, Web resources, and all course materials.
Reference
The Joint Commission. (2019, August 8). Sentinel event policy and procedures. Retrieved from http://www.jointcommission.org/sentinel_event_policy_and_procedures/
At the facility where I work, a Sentinel Event is defined as an unexpected event that involves death or serious physical or psychological injury (Kaiser Permanente, 2019). If a Sentinel Event occurs, the patient should be immediately stabilized, if possible. The event should then be immediately reported to the department manager and risk management. Care must be taken to preserve equipment or supplies that may have failed and cause the patient injury. The policy at my facility is similar to the policy of the Joint Commission. The major difference that I noted, was that the Joint Commission did not specify that psychological injury was included in Sentinel Event reporting. It is also optional to report to the Joint Commission, although highly recommended.
The Joint Commission must be incorporated into creating policy and procedures to ensure patient safety. Healthcare workers can feel profound guilt as the result of a medical error (Rodziewicz, 2022). To reframe errors as learning opportunities, the Joint Commission can help highlight process failures that can facilitate learning, in a no-fault environment. Healthcare workers will be less likely to report errors in a culture of blame. If errors can be reported and used as an opportunity to improve safety measures, then progress can occur. The Joint Commission can help to ensure that safety measures are globally recognized and need not occur at each site. Information shared across many facilities can prevent the same errors from occurring repeatedly. Sharing safety information and removing blame from the healthcare worker can help to foster a safer environment for all patients.
References
Kaiser Permanente. (2019). SOS Spotlight on Safety. KPNursing.
https://kpnursing.org/_SCAL/professionaldevelopment/orientation/SanBernardino/2019%20SOS%20-%20HC.pdf
Rodziewicz, T. L., Houseman, B., & Hipskind, J. E. (2022). Medical Error Reduction and Prevention. In StatPearls. StatPearls Publishing.
Sentinel events are those we as nurses hope will never occur on our watch, or will not occur period in our hospital. Although they are unfortunate it is essential to have regulations and regulatorty agencies that overlook these type of events. At our hospital, hourly rounding has been a safety practice that we have been following for years. Assessing patients hourly not only reduces call lights and increases patient satisfaction, but most importantly it helps prevent falls and keeps nursing staff aware of any medication side effects or harm (Daniels, 2016). However there have been times where even with this hourly rounding, patient unfortunately suffer sentinel events.
For instance recently there was a patient who commited suicide at one of our local hospitals. Patient apparently hung himself from the bedrailing using a gait belt. This was a sentinel event. The nurse had done her hourly rounding, yet the patient still was able to harm himself.
Regulations for sentinel events are similar at my facitily as well as JCAHO. These regulations need to be in place in order to promote transparecy in a hospital. It also promotes a culture of safety as a hospital can learn what went wrong and implement ways in which the same event would not occur again. In the above mentioned suicide, we have a suicide assessment scale which those at risk could be properly assessed, identified and treated (Posner et al., 2011).
Daniels J. F. (2016). Purposeful and timely nursing rounds: a best practice implementation project. JBI database of systematic reviews and implementation reports, 14(1), 248–267. https://doi.org/10.11124/jbisrir-2016-2537
Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., Currier, G. W., Melvin, G. A., Greenhill, L., Shen, S., & Mann, J. J. (2011). The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. The American journal of psychiatry, 168(12), 1266–1277. https://doi.org/10.1176/appi.ajp.2011.10111704