. Identify any breach of practice, knowledge deficit, failure to follow standards such as universal or standard precautions or breach of regulatory and/or professional/institutional standards/policies/procedures that led to your Adverse Event (your infectious process).

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January 14, 2021
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January 14, 2021

. Identify any breach of practice, knowledge deficit, failure to follow standards such as universal or standard precautions or breach of regulatory and/or professional/institutional standards/policies/procedures that led to your Adverse Event (your infectious process).

 
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Now, pretend you are the Director of Risk Management. A serious Adverse Event (Sentinel Event) related to an infectious process happened under your watch in your facility. You identified this Adverse Event in Assignment 1
(however, you may replace it or modify it if you want). Include in this paper:
1. The CEO of the Practice Setting.
2. Staff (such as MD, OT, PT, RN, NP or PA) involved in the Sentinel Event.
3. The Director of that Staff’s Practice Setting.
4. The outside Regulatory person (such as from the Department of Health, The Joint Commission, OSHA or FMEA) who is there to investigate, and make sure there is a process to deal with the Sentinel Event.
5. A patient representative, and/or other staff if you want. 
Then: 
1. Identify any breach of practice, knowledge deficit, failure to follow standards such as universal or standard precautions or breach of regulatory and/or professional/institutional standards/policies/procedures that led to your Adverse Event (your infectious process).
2. Discuss what happened—the “who, what, when, where, why and how.”
3. Then, cite the correct process or processes using class related material.
4. Then present a corrective action plan using FOCUS, and finish with a Policy/Procedure and an Education Plan and a PDCA Quality Improvement/ Assurance/Performance (monitoring) Plan. 
(Key concepts to include in you paper:
1. Infection Control/Universal and Standard Precautions.
2. RCA – Root Cause Analysis
3. FMEA – Failure Mode and Effects Analysis
4. Quality Improvement/Assurance or Performance Improvement.
5. FOCUS and PDCA – Please research the meaning.
6. SBAR – Situation-Background-Analysis and Recommendation.
7. Time Out.
8. Sentinel Event)
9. Use new terminology used in the course.
Please reference resource material such as The Joint Commission, New York State Department of Health, the CDC, or other governmental, and other for profit or not for profit organizations.
Submit this Assignment (@ 5 pages) in appropriate academic format citing references.]]>
 
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