Question

Review the Hospital Acquired Condition (HAC) list from Appendix 7-B on page 79 in your Principles of Risk Management and Patient Safety text.

Imagine that you are the risk manager of an accountable care organization. Select one never event from the list on page 79 and describe how you would institute proactive monitoring for POAs. For this discussion:  A foreign object (such as a sponge or needle) inadvertently left in a patient after surgery

Describe how you would intervene when an HAC occurred.

Identify departments or functional areas that would be involved in reporting to regulatory entities.

Describe problem resolution.

Describe how you would use the data from the lesson learned for organizational improvement.

Answer 1

1) retained surgical items is now the preferred item.because foreign bodies can be object found or left in a patient eg:bullets,coin ,bottles and sharpnel.

2)the minimal requirements for intention are a case in which an incision is made and surgical items are used inside the patient.eg(sponge,needle,instruments).

Solution for the problem: minimally invasive approaches are used in many events of retention have been reported.

The retained items was discovered on an incidental x-ray.

After an event occurs,hospital clinical staff and risk management team assembles to conduct root cause and focused review analysis.

Risk management and patient safety precautions are:

Surgical fires

Surgical fire safety training programs.

Physical restraints.

Violence in health care facilities.

Lesson for organisational improvement:

After an event occurs Hospital clinical staff and risk management team assembles to conduct root cause and focused review analysis.

Education on practitioners following a standardized accounting policies of initial counting before closing a cavity within a cavity, before wound closure begins , at skin closure or end of procedure and at the time of scrub or circulating nurse he is relieved.

Education on communication and collaboration among operating room team members.

Utilisation of effective communication skills learned and crew resource management training and team.

The use of safe,assistive technological advances to assist in the counting process.