|Perfect Number of Pages to Order||5-10 Pages|
Sentinel Event Research Paper Assignment
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. For this assignment, first, review details from the Week 2 and Week 3 discussions, including responses from peers, as well as instructor gradebook feedback.
Then, you will focus on the parts below to develop a cohesive plan to address the sentinel event. Address the following in the Executive Summary to CEO template
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
Part 3: Root Cause Analysis Report