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FPX4030.docx (2) FPX4030 Determining the Credibility of Evidence and Resources COURSE:

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FPX4030.docx (2) FPX4030 Determining the Credibility of Evidence and Resources COURSE: NURSE-FPX4030 Making Evidence Based Decisions Describe a Quality or Safety Issue A sentinel event is an une ... xpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase œor the risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Root cause analysis is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not on individual performance. An adverse drug event (ADE) is harm experienced by a patient resulting from exposure to a medication. Opioid analgesic use in the hospital setting is usually safe, but it is also associated with serious ADEs. (Comprehensive Accreditation Manual for Hospital p.2, 2019). This paper will describe in depth an example of a sentinel event in my personal practice experience utilizing opioids post- operative as well as explore the root-cause analysis of the medication error. Example of a Sentinel Event A 70-year-old man underwent a total hip replacement, which is typically a standard procedure. During surgery he received opioid analgesics, anesthetics, pain medication and a general anesthetic. While in the post-anesthesia car. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. .. . . . . . . . . . . . . . . . . . .. . . . . [Show More]

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