3. Dr. Sheryl Cornelius, EdD, MSN, RN

4. Upon completion of this module the student will be able to:  Describe the role of the nurse in quality improvement.  Outline what constitutes a sentinel event.  Articulate reporting of a sentinel event.  Analyze how sentinel events are associated with quality improvement.  Describe the role of the nurse in reporting.

5.  The need to improve care  The need to maintain quality care  The need to continue to improve quality within the organization

6. Institute of Medicine (IOM) report  To Err is Human: Building a Safer Health System  98,000 deaths in hospitals each year  Current system fragmented and poorly organized Committee on the Quality of Health Care in America  Crossing the Quality Chasm  Chronic diseases now leading cause of illness, disability, health problems  Current system complex, fragmented, disorganized

7.  Observing any problems  Notifying the proper personnel  Taking part in pilot studies the facility may undertake

8. Sentinel Event  an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof Never Event  extremely rare medical errors that should never happen to a patient

10.  What happened?  Why did it happen?  What circumstances surrounded the event?  Framework for conducting a root cause analysis from TJC: http://www.jointcommission.org/Framework _for_Conducting_a_Root_Cause_Analysis_and _Action_Plan/

11.  Change the climate of reporting  Attend any briefings the facility may have on changes to your systems  Keep a hands on approach in the facility workings

12. Find an example online and discuss how the facility handled it

13.  The Institute of Medicine: To Err Is Human: Building a Safer Healthcare System http://www.iom.edu/Reports/1999/To-Err-is- Human-Building-A-Safer-Health-System.aspx http://www.iom.edu/Reports/1999/To-Err-is- Human-Building-A-Safer-Health-System.aspx  The Institute of Medicine: Crossing the Quality Chasm http://www.iom.edu/Reports/2001/Crossing- the-Quality-Chasm-A-New-Health-System-for- the-21st-Century.aspx http://www.iom.edu/Reports/2001/Crossing- the-Quality-Chasm-A-New-Health-System-for- the-21st-Century.aspx  The Joint Commission: Read the “Sentinel Event Alert” under Topics tab http://www.jointcommission.org/ http://www.jointcommission.org/

14. North Carolina Concept-Based Editorial Board, (2011). Nursing: A Concept Based Approach. Upper Saddle River, New Jersey: Pearson Education, Inc. Marquis, B. L. & Huston, C. J. (2009). Leadership roles and management functions in nursing: Theory and application. (6 th ed.). Philadelphia : Lippincott, Williams & Wilkins. Taylor, C., Lillis, C., Lemone, P., (2011). Fundamentals of Nursing: The Art & Science of Nursing Care. (7 th ed.) Philadelphia, Lippincott, Williams & Wilkins.