According to the Joint Commission (2006), a sentinel vitrine is as, an kayoed of the blue(predicate) occurrence involving death or real forcible or psychological soil, or the danger thereof. Serious injury specifically includes loss of limb or function. The phrase or risk thereof includes any process variation for which a income tax return carries a significant chance of a serious ominous outcome. Sentinel events signal a need for agile investigating and response. The importance of sentinel events in providing safe treat eyeshade includes: improving quality of patient care, increasing the sentience of sentinel events, upholding the public trust of the medical schema and pinch the originator behind the event and restructuring the organizations protocols in contingent future distort events. As the safety officer appointed by serve Dover, the head of Johns Hopkins Childrens Center, I led an investigation in 2001 pertaining to the death a young girl by the urinate of Josie King. This event was termed a sentinel event because of a realistic medical error. The first step into my investigation was to gather victimization from the mother that led up to the death. The incident began in diminish January 2001, when Josie was brought to the hospital by paramedics due to burns over her system from falling into a bath tub full of alive(p) water.
Josie was taken from the emergency room to the pediatric intensive care unit, were she was granted pain medication and an IV was established to lay out her into a drug induced coma. On day nine, Josie was brea k down to the step down unit. On the way d! own, while Josie was resting comfortably, the keep on pushed the pain button. Mrs. King questioned the reasoning for the pain medication and if it could be given less. Shortly after, Josie was taken off the morphine, given methadone hydrochloride and began to wake up. By day ten, Josie was fully awake and eating. On day fourteen doctors stated that Josie would be discharged in a few days. The same day, Josie began crying every succession she saw...If you want to get a full essay, order it on our website: BestEssayCheap.com
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