weekly_question 9/6/2024

[Admin]

A patient undergoes anal sphincterotomy for fistula-in-ano. To keep stool from the operative field, the surgeon packs a temporary ray-tec sponge in the rectum with the intention to remove it at the end of the case. The surgeon completes the procedure and the counts are correct. In the PACU the parents noted that there is a sponge in the diaper. The child is otherwise doing well. Federal legislation mandates reporting this event to the

A Scrub nurse

B Hospital Safety Committee

C Divisional M and M committee

D Parents

E Primary care provider

[Admin]

Correct answer
B Hospital Safety Committee

To ensure that all patients are protected from injury while receiving care, The National Quality Forum (NQF) has developed and endorsed a set of Serious Reportable Events (SRE’s), This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care. A serious reportable event (SRE) is an incident involving death or serious harm to a patient resulting from a lapse or error in a healthcare facility. An SRE’s are "preventable, serious, and unambiguous adverse events that should never occur.” SREs are commonly referred to as "never events." An increasing number of states require that SREs are reported.

The NQF has compiled a list of 28 SREs in six categories.

Surgical events include:

• Surgery on the wrong body part
• Surgery on the wrong patient
• Wrong surgery on a patient
• Leaving a foreign object in a patient

Product or device events include:

• Death or disability as a result of contaminated drugs or faulty devices received through a healthcare facility.
• Death or disability resulting from the wrong device used or a device functioning other than as intended
• Death or disability associated with intravascular air embolism that occurs while in care

Patient protection events include:

• Sending an infant home with the wrong parents
• Death or serious harm suffered when a patient leaves the facility without permission
• Suicide, or attempted suicide that results in serious harm, while a patient in a healthcare facility

Care management events include:

• Death or serious harm as a result of a medication error, such as the wrong dosage, wrong medication or medication given to the wrong patient
• Death or serious disability as a result of being given incompatible blood or blood products
• In a low risk pregnancy, maternal death or serious harm as a result of labor or delivery in a healthcare facility
• Stage 3 or 4 pressure ulcers (bed sores) acquired during care
• Artificial insemination conducted using the wrong egg or donor sperm

Environmental events include:

• Death or serious disability as a result of electric shock
• Delivery of the wrong gas in an oxygen line
• Death or serious disability resulting of a fall while in care
• Patient death or significant disability as a result of the use of restraints or bedrails while in care

Criminal events include:

• Any patient care conducted by an unauthorized person
• Patient abduction
• Sexual assault of a patient while in care
• Death or serious injury of a patient or staff member as a result of an assault on the grounds of a healthcare facility.

[Audrey]

C

[Manal Dhaiban]

B
I would assume that the surgeon would have told the scrub nurse at the end of the procedure.

[Bashar Qassas]

A

[Faisal Ali]

A

[Dr.Shumaila]

A

[Dr Lu]

B.
This we assume was reported to the Scrub nurse at the during and at the end of the procedure

[Admin]

Correct answer
B Hospital Safety Committee

To ensure that all patients are protected from injury while receiving care, The National Quality Forum (NQF) has developed and endorsed a set of Serious Reportable Events (SRE’s), This set is a compilation of serious, largely preventable, and harmful clinical events, designed to help the healthcare field assess, measure, and report performance in providing safe care. A serious reportable event (SRE) is an incident involving death or serious harm to a patient resulting from a lapse or error in a healthcare facility. An SRE’s are "preventable, serious, and unambiguous adverse events that should never occur.” SREs are commonly referred to as "never events." An increasing number of states require that SREs are reported.

The NQF has compiled a list of 28 SREs in six categories.

Surgical events include:

• Surgery on the wrong body part
• Surgery on the wrong patient
• Wrong surgery on a patient
• Leaving a foreign object in a patient

Product or device events include:

• Death or disability as a result of contaminated drugs or faulty devices received through a healthcare facility.
• Death or disability resulting from the wrong device used or a device functioning other than as intended
• Death or disability associated with intravascular air embolism that occurs while in care

Patient protection events include:

• Sending an infant home with the wrong parents
• Death or serious harm suffered when a patient leaves the facility without permission
• Suicide, or attempted suicide that results in serious harm, while a patient in a healthcare facility

Care management events include:

• Death or serious harm as a result of a medication error, such as the wrong dosage, wrong medication or medication given to the wrong patient
• Death or serious disability as a result of being given incompatible blood or blood products
• In a low risk pregnancy, maternal death or serious harm as a result of labor or delivery in a healthcare facility
• Stage 3 or 4 pressure ulcers (bed sores) acquired during care
• Artificial insemination conducted using the wrong egg or donor sperm

Environmental events include:

• Death or serious disability as a result of electric shock
• Delivery of the wrong gas in an oxygen line
• Death or serious disability resulting of a fall while in care
• Patient death or significant disability as a result of the use of restraints or bedrails while in care

Criminal events include:

• Any patient care conducted by an unauthorized person
• Patient abduction
• Sexual assault of a patient while in care
• Death or serious injury of a patient or staff member as a result of an assault on the grounds of a healthcare facility.