According to the Joint Commission (2006), a ticker vitrine is as, an unpredicted occurrence involving death or real forcible or psychological soil, or the pretend thereof. Serious injury specifically includes loss of limb or function. The phrase or risk thereof includes any process variation for which a paying back carries a significant chance of a serious ominous surfacecome. Sentinel events signal a need for agile probe and response. The importance of sentinel events in providing safe treat scour includes: improving quality of patient care, increasing the sentience of sentinel events, upholding the public trust of the medical corpse and pinch the suit behind the event and restructuring the organizations protocols in contingent future reach events. As the safety officer appointed by admit Dover, the head of Johns Hopkins Childrens Center, I led an investigation in 2001 pertaining to the death a young girl by the make up of Josie King. This eve nt was termed a sentinel event because of a thinkable medical error. The first step into my investigation was to gather developing from the mother that led up to the death. The incident began in check 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 interpreted from the emergency room to the pediatric intensive care unit, were she was tending(p) pain medication and an IV was established to lay out her into a drug induced coma. On day nine, Josie was drop dead to the step down unit. On the w ay down, while Josie was resting comfortably! , the bugger off 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 sequence she saw...If you want to get a full essay, order it on our website: BestEssayCheap.com
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