Sentinel Event
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Sentinel Event
A sentinel event is "any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness".https://www.pressganey.com/docs/default-source/default-document-library/hpi-white-paper---sec-amp-sser-measurement-system-rev-2-may-2011.pdf Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed, and that undesirable trends or decreases in performance are caught early and mitigated. Specific events requiring review Sentinel events include "unexpected occurrences involving death or serious physical or psyc ...
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Joint Commission
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world. A majority of US state governments recognize Joint Commission accreditation as a condition of licensure for the receipt of Medicaid and Medicare reimbursements. The Joint Commission is based in the Chicago suburb of Oakbrook Terrace, Illinois. History The Joint Commission was formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and previous to that the Joint Commission on Accreditation of Hospitals (JCAH). The Joint Commission was renamed The Joint Commission on Accreditation of Hospitals in 1951, but it was not until 1965, when the federal government decided that a hospital meeting Joint Commission accreditation met the Medicare Conditions of Participation, that accreditation had any official impact. However, Se ...
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Root Cause Analysis
In science Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe. Science may be as old as the human species, and some of the earliest archeological evidence for ... and engineering, root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. It is widely used in IT operations, manufacturing, telecommunications, Process control, industrial process control, accident analysis (e.g., in aviation, rail transport, or nuclear plants), medicine (for medical diagnosis), healthcare industry (e.g., for epidemiology), etc. Root cause analysis is a form of deductive inference since it requires an understanding of the underlying causal mechanisms of the potential root causes and the problem. RCA can be decomposed into four steps: * Identify and describe the problem clearly * Establish a timeline from the normal situation until the problem ...
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Child Abduction
Child abduction or child theft is the unauthorized removal of a Minor (law), minor (a child under the age of Age of majority, legal adulthood) from the Child custody, custody of the child's Parent, natural parents or Legal guardian, legally appointed guardians. The term ''child abduction'' includes two legal and social categories which differ by their perpetrating contexts: abduction by members of the child's family or abduction by strangers: * Parental child abduction is the unauthorized custody of a child by a family relative (usually one or both parents) without parental agreement and contrary to family law ruling, which may have removed the child from the care, access and contact of the other parent and family side. Occurring around parental Legal separation, separation or divorce, such parental or familial child abduction may include parental alienation, a form of child abuse seeking to disconnect a child from targeted parent and denigrated side of family. This is, by far, ...
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Infant Mortality
Infant mortality is the death of young children under the age of 1. This death toll is measured by the infant mortality rate (IMR), which is the probability of deaths of children under one year of age per 1000 live births. The under-five mortality rate, which is also referred to as the ''child mortality rate'', is also an important statistic, considering the infant mortality rate focuses only on children under one year of age. In 2013, the leading cause of infant mortality in the United States was birth defects. Other leading causes of infant mortality include birth asphyxia, pneumonia, congenital malformations, term birth complications such as abnormal presentation of the fetus umbilical cord prolapse, or prolonged labor, neonatal infection, diarrhea, malaria, measles, and malnutrition. One of the most common preventable causes of infant mortality is smoking during pregnancy. Lack of prenatal care, alcohol consumption during pregnancy, and drug use also cause complications ...
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Neonatal Jaundice
Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin levels. Other symptoms may include excess sleepiness or poor feeding. Complications may include seizures, cerebral palsy, or kernicterus. In most of cases there is no specific underlying disorder (physiologic). In other cases it results from red blood cell breakdown, liver disease, infection, hypothyroidism, or metabolic disorders (pathologic). A bilirubin level more than 34 μmol/L (2 mg/dL) may be visible. Concerns, in otherwise healthy babies, occur when levels are greater than 308 μmol/L (18 mg/dL), jaundice is noticed in the first day of life, there is a rapid rise in levels, jaundice lasts more than two weeks, or the baby appears unwell. In those with concerning findings further investigations to determine the underlying cause are recommended. The need for treatment depends on bilirubin levels, the age of the child, and the u ...
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Retained Surgical Instruments
A retained surgical instrument is any item inadvertently left behind in a patient’s body in the course of surgery. There are few books about it and it is thought to be underreported.Gibbs, Verna C. “Chapter 22. The Retained Surgical Sponge.” As a preventable medical error, it occurs more frequently than "wrong site" surgery. The consequences of retained surgical tools include injury, repeated surgery, excess monetary cost, loss of hospital credibility and in some cases the death of the patient. Mistakes and consequences In any given typical surgery, an estimated 250–300 surgical tools are used.Institute of Medicine. ''To Err Is Human- Building a Safer Healthcare System'' pg.43 The number significantly increases to 600 when a larger surgery is performed, thus increasing the chance of the surgeon losing an instrument. Types of forgotten instruments There are many different types of tools that have been left behind during a surgery. Common instruments are needles, kn ...
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Rape
Rape is a type of sexual assault usually involving sexual intercourse or other forms of sexual penetration carried out against a person without their consent. The act may be carried out by physical force, coercion, abuse of authority, or against a person who is incapable of giving valid consent, such as one who is unconscious, incapacitated, has an intellectual disability, or is below the legal age of consent. The term ''rape'' is sometimes used interchangeably with the term ''sexual assault.'' The rate of reporting, prosecuting and convicting for rape varies between jurisdictions. Internationally, the incidence of rapes recorded by the police during 2008 ranged, per 100,000 people, from 0.2 in Azerbaijan to 92.9 in Botswana with 6.3 in Lithuania as the median.
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Suicide
Suicide is the act of intentionally causing one's own death. Mental disorders (including depression, bipolar disorder, schizophrenia, personality disorders, anxiety disorders), physical disorders (such as chronic fatigue syndrome), and substance abuse (including alcoholism and the use of and withdrawal from benzodiazepines) are risk factors. Some suicides are impulsive acts due to stress (such as from financial or academic difficulties), relationship problems (such as breakups or divorces), or harassment and bullying. Those who have previously attempted suicide are at a higher risk for future attempts. Effective suicide prevention efforts include limiting access to methods of suicide such as firearms, drugs, and poisons; treating mental disorders and substance abuse; careful media reporting about suicide; and improving economic conditions. Although crisis hotlines are common resources, their effectiveness has not been well studied. The most commonly adopted metho ...
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Radiation Therapy
Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a therapy using ionizing radiation, generally provided as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator. Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body. It may also be used as part of adjuvant therapy, to prevent tumor recurrence after surgery to remove a primary malignant tumor (for example, early stages of breast cancer). Radiation therapy is synergistic with chemotherapy, and has been used before, during, and after chemotherapy in susceptible cancers. The subspecialty of oncology concerned with radiotherapy is called radiation oncology. A physician who practices in this subspecialty is a radiation oncologist. Radiation therapy is commonly applied to the cancerous tumor because of its ability to control cell growth. Ionizing radiation works by damaging the DNA of cancerous tissue ...
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Food And Drug Administration
The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food safety, tobacco products, caffeine products, dietary supplements, Prescription drug, prescription and Over-the-counter drug, over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices (ERED), cosmetics, Animal feed, animal foods & feed and Veterinary medicine, veterinary products. The FDA's primary focus is enforcement of the Federal Food, Drug, and Cosmetic Act (FD&C), but the agency also enforces other laws, notably Section 361 of the Public Health Service Act, as well as associated regulations. Much of this regulatory-enforcement work is not d ...
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Healthcare In The United States
The United States far outspends any other nation on health care, measured both in ''per capita'' spending and as a percentage of GDP. Despite this, the country has significantly worse healthcare outcomes when compared to peer nations. The United States is the only developed nation without a system of universal health care, with a large proportion of its population Health insurance coverage in the United States, not carrying health insurance, a substantial factor in the country's Mortality displacement, excess mortality. Healthcare is provided by many distinct organizations, made up of insurance companies, healthcare providers, hospital systems, and independent providers. Health care facilities are largely owned and operated by private sector businesses. 58% of community hospitals in the United States are Non-profit hospital, non-profit, 21% are government-owned, and 21% are For-profit hospital, for-profit. According to the World Health Organization (WHO), the United States spe ...
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