Now that you have worked with the team at Pleasantville to address many of their Joint Commission Citations, you are ready to return to Mercy armed with new insights into how to address their many citations. Many of the citations will be similar to those you helped solve at Pleasantville.
1. Some of the sentinel events that have occurred at Mercy are listed below:
- A high number of patient falls resulting in at least minimal injury.
- Five incorrectly identified patients leading to medication errors that caused death in one case and severe disability in four others.
- Ten inaccurate and late reporting of laboratory findings on patients due to poor communication plans leading to delay in treatment.
- Lack of timely response to medical equipment alarms leading to patient demise.
- A high incidence (10) of hospital-acquired infections due to improper handwashing by staff, improperly sterilized instruments and equipment, and lack of sufficient Personal Protective Equipment (PPE)
- A high incidence (10) of hospital-acquired post-surgical infections due to poor sterile technique.
- Two instances of wrong-site surgery resulting from a lack of protocol for marking the correct site prior to entering the operating room.
- One hemolytic transfusion reaction resulting from the administration of the wrong blood product.
- One newborn was discharged to the wrong family.
- One suicide of a patient under care in the mental health unit. Two incidents of ventilator-acquired pneumonia.
2. Choose a minimum of 5 sentinel events and develop a policy/protocol poster for each event to prevent or decrease the likelihood of the event occurring in the future.
