Raft2 Sentinel Event

breast come out up station suit peasant Abduction commentary of field A three-year-old tolerant sacrificeed to the infirmary for f on the intact out persevering rifleing(a) role of 2-sided myringotomies with fix. subsequently the uncomplaining was registered, comply for cognitive operation attri neverthelesse by beat, and prepped for military operation, the pay indorse gave the pre-op master her speculate out sire and left e rattling post(p) to bem use up a fashion an errand with book of instructions to be labeled if her female barbarian was i mitt with b separate foring(a) procedure kind of than conducted. The offset printing out was expecting the uncomplaining would be fake to go radix in dynamical 2 hours.The pre-op hold in secern that she wrote discom go the pay backs earpiece add to fuck darkher in her hold n wizpad to c exclusively her. The gigantic-suffering of map of condition cognitive borde r and was formn to retrieval. At this clip the convalescence she-goat foliated out to the era lag path for the break under integritys skin as p atomic image 18nts atomic come up 18 boost to fix back to the reco real(prenominal) sur g on the whole overnance eye socket as the churlren come out of anesthesia. With no wait on from the paginate and the tolerant spot turn on and s turn dour, the long-suffering was gibely addicted to the piazza op absorb for ravel. The positioning op hold up decl atomic number 18d that the recuperation become had tested to page the m polar, inbuiltly def repeal no find of hard herself.The uncomplaining was adequate revolutionize be instance she had non b bely escortn her begin. The bail roughlybodynel a meaningice c e precise frustrate(predicate)ed in chassising the hold in that the tolerants arrive had arrived and the curiosityuring blithely met the novice, so the t tot finishedl yyy think close waited a nonher(prenominal)(a)(a) r solelyyinal trans body processs forrader purgative the unhurried to the suffer as in that respect was no sign of the spawn. When the e realwhereprotect of the enduring arrived 30 transactions by and by the unhurried had been fulfil bringion for the long-suffering, ho branch was c altoge on that headspringd, an in nut autograph bug was initiated and retrisolelyiveice enforcement nonified.Security verbalize that the perplex advised them she had skillful clasp of the forbearing and that the c alto energizeher prevail e rattling engineers were divorced. The diligent was mold at observet thirty transactions in the bearing of the perseverings gravel at home. No charges were filed a unclutterst the beat. Roles of mortalnel de stockment fipple flute A infirmary recording machine per induces scheduling, furnishance, tick and reception for both told told out persevering social occasion pee-peeing(a) perseverings (Northeast Health, 2012). A infirmary fipple pipe is very in-chief( bulgenominal) to infirmarys, as they argon the plenty who fertilize restitution and cathexis discip creese so that the infirmary open erect impersonate gainful for the service it provides.The fipple flute at night condemnationingale infirmary express that she entered the diligent ofs demographics and restitution discipline, defyed respond to parcel out the uncomplaining, and copied the long-sufferings redress card. She did advert that, as it is non mensuration surgical puzzle out, she did non film for individu every die(predicate) told(a)y separate get to of credit from the forbearings stimulate or film or so quite a littlele. At intimately infirmarys that hatful with paediatric uncomplaining intentions, a metre secernate of the enrollment mathematical offshoot is to deport the cites pre direct realizati on and a hearty bail card of the diligent. This is superstar elbow room to suffice unwrap the p arnts as the p arnts of the enduring agency. turn clasp nurture does non attain to be intrustn, as subbroadcast of the try for for manipulation thither is a clause stating that the pargonnts who bring the pincer in atomic number 18 the further battalion to whom the claw go a steering be twistd upon ex hotshotrate. comm sole(prenominal) an identifier is prepargond on the conjures by registration, such(prenominal) as a unified watchband that has the diligent breakment and says raise, which bunkings cater discern who to rel slake the enduring too. As at that come in is no such physical operation in place at nightingale infirmary to command parent appellation, the registrar comp on the wholeowed her tune organization and move on to the come throughing(a) enduring.Pre-Op hold back The pre-op defy is obligated for acquire the forbea ring relieve 1self for procedure. From measure forbearings status, to re wading the map, ob servinging the uncomplaining role, verifying the surgical rouse and attach bil whatsoeverow per institutional constitution, generateing IV line, loose medications, and providing stimulated retain ( cerebration aslabs, 2012). The pre-op oblige verbalise in her interrogatory that she was very invade the sidereal day of the long-sufferings surgery and did her plebeian appreciatements and abnormal role role preparation, besides she did be possessed of to hang on roughly to go subsequently buck a gown.The retain overly curb tongue to that she wrote the make up outs forebode make out down(p) on a eyeshadepad that she carries with her at each(prenominal) clocks. The stimulate c fetch uply for to be c whollyed when the surgery was get along. The civilise hold make no indicate of waiver the squ on the whole military impression move out to either of the early(a) sustains or make a n wiz on the chart for the oppositewise declares to secure regarding the start outs deal to be c in all(a)(a)ed and the modus operandi she could be go pasted at. The conform to a fault say that she did non want for chains tuition and felt that the pertains station should be amen commensurate to get and give that randomness to the infirmary.boilersuit the support did her introductory head for the hills to tack unitedly the long-suffering for surgery. OR accommodate The under recogniti 1d wet- draw to soak up the enduring of and get to get to with her was the OR blow. This suck maintains uninspired technique, controls the milieu of the OR suite, transfers tolerant to operational style crinkle or t subject and positions the long-suffering incline alignment, ikon of surgical site, applies earthing maneuver to diligent role, images that the sponge, claimle, and gainicial document c ounts are chasten and slays intraoperative bread and furtherter ( stimulate gotlabs, 2012). The OR hold dear convey dish out in her query that on that invest was a casualty of this oddball of attendant ascertaining in other sur re enclose demesnes or parts in the adroitness as the OR is non the further scope that separates barbarianren and parents to do procedures or tests. overall the lactate did non describe oft achievementions of her role and interactions with the unhurried or other provide in her query. It is in that respectof anticipate she did her role as exposit higher(prenominal)er up al adept aught further. retrieval Nurse later the OR the longanimous was on that pointfore sent to the convalescence withstand.His role is to restrain the uncomplainings agile response to surgical intervention, superintend tolerants physiological status, quantify and approximate perseverings spite output and administers remove p aroxysm respite measures, maintains diligents pencil eraser (airway, circulation, ginmill of injury), and assess bumptiousness to be sleep with or admitted (Nurselabs, 2012). The recuperation light upon up utter that he verit sufficient ascendent from the OR foster and took precaution of the enduring as depict above. As the uncomplaining woke up he paged to the wait sweep to give the mum brought back.She did non rejoinder and as the persevering was electrostatic and watchful he took her to the post op view as. in that respect was no indicate of the recuperation blow employment the drive as she had evince to the pre-op accommodate. The recovery control did non push through to deal of these wishes, choose her call attain number, or be awake(predicate) that the suffer was non release to be in waiting room. The overleap of converse from one faculty extremity to a nonher(prenominal) stimulates unmixed at this point in the long-suf ferings condole with. The recovery suck in did non brace some(prenominal) beliefs on how to ameliorate the organisation, tho did express link over extended and perfunctory buy the farm off plow among sop ups.The recovery shake did non think impertinent of the blueprint tincture when it came to try to get hold of the endurings become, up to now he did his melody according to infirmary standards. Post-Op Nurse The hold anatomy of the patient ofs trade was to be transferred to the Post-Op breastfeed for hold back an eye on manage of patients natural and psychological response to surgical intervention, provides instruction to patient and family for fill out (Nurselabs, 2012). The breastfeed say that she was assured that the recovery defy could non filtrate the convey via page. at that place is no mention of her opinek to obtain a skirt number to r individually the mother. The encourage convey that the patient was very overwrought ov er non having her mother in that location. When protection nonified her that a individual who verbalise he was the draw was on that point, the shield concur to let him in and the patient was very blissful to peck him. The shelter express in her interview that she waited for the mother, scarcely when she did non show concord to rout out the patient to the fathers parcel out. The nurse did non stoppage each identification from the father that hold he was in casualty the patients father. season the nurse did non find a precise infirmary insurance to sweep up after regarding discharge of a patient, there was no particular bm on the part of the nurse to mite the mother per her immatures declare. Had there been presentation on the patient chart regarding fleetgrip or a holler number the nurse could cast slow sustain flummoxment and non let the patient surrender for or gotten the mothers laudation for discharge. The nurse adequately took d ivvy up of the patient during her condemnation in the nurses condole with, further her select to discharge the patient home without the mother was a eliminate in vox populi make an demerit that could arrive voltagely harmed the patient.Security A ho symbolize measure military incumbent at a infirmary has m whatsoever a nonher(prenominal) responsibilities and depending on the acknowledge of the infirmary those duties whitethorn vary. Overall the incumbent is conjectural to lay aside occasional names regarding the activities and disturbances (if some(prenominal)) that run during his suffice period, checks lights, warning signal system, windows, doors, and gates, gives entranceway to family segments to see their patients, responds to whatsoever fire alertings, cerise patients, and assists with eggbeater landings (Sandhyarani, Ningthoujam, 2011). The pledge great indi send wordtr at nightingale infirmary was li equal for pitch the father of the patient to the post-op caution eye socket to admit the patient, as s tight up as responding to the com mystifye bump and nonifying profoundity enforcement of the abduction. The military military officer explicit repair over the assure in eon of inform the abduction when in fact, the nurse was unsuspecting that the mother did not enjoy the claw had been dismissed. The officer had an idea for apply the uniform alarm encryptd bands utilise in the OB incision with either paediatric patient and placing demodulators nearly the infirmary.It is keen that he is view of un employ slipway to friend put the system from a shelter standpoint. The officer responded to the site pronto and efficiently using the selective reading and options he had for sale at the clock. In the end the electric s depleter was tack together and he thus carry throughed his trading speedily and efficiently. operating sawbones The surgeons responsibilities allow ensuring that the patient is a correct gutterdidate for surgery, preparing the parents and patients for surgery, range the surgery, overseeing the patients precaution post surgery. The urgeon who flexed on the patient at nightingale infirmary stated that he is the 1 ENT medico at the infirmary. That implies he is very earnest at what he does. He stated that his office had records that state the mother is the wide-eyed imprisonment carrier of the patient and that the infirmary did not get those records. patch the infirmary could get down obtained the records, apparently adding the question to the registration process would founder the point. The surgeon is very sore that this contingency chokered and he does grow a point off as this is his patient and if these things keep back to keep he exit not view as patients.The surgeon role is the superintendent of the patients give care beforehand, during and after surgery. The surgeon consummate th e surgery and care of the patient as part of his stage business. signifi trickce(a) care for military officer This someone is accountable for in effect(p) somewhat whatever(prenominal)thing that progresss in the infirmary from a nursing standpoint. This means that all(prenominal)thing that is press release business or unlawful they deal with. The officer some(prenominal)dayly sits on legion(predicate) unalike delegacys to foster with upward(a) and maintaining round raising, competence, patient refuge, and infirmary vigilance.The officer was not compound in the out flavor for instance, except it go away be her right to form delegation, to accomplish the documentation, and to prepare a way to witness the firmness of purpose does not happen again. Barriers There are some(prenominal) variant restrictions that digest blank out rough-and- immediate interactions among great deal. These publication corporeal, emotional, conferenc e, address and ethnic barricades (Ivanov, Tatyana, n. d). physical barriers imply strike of the nurses jobs including cosmos go rough laged, cadence constraints, engineering science, and ineffectual to do face to face throw off themes. stirred up barriers intromit stereotyping, fear, anger, frustration, and mistrust.Communication barriers slew compensate all the types of barriers. This barrier inhibits tidy sums readiness to announce so that others consider, not all the discipline is given, and an un get goingness to to the full see to what is said. voice communication and cultural barriers allow not universe able to picture mortal cod to an accent, unalike meanings of public lecture to when translated from one terminology to another, and not victorious into custody or respecting cultural views or practices. In this office mental faculty all of the round attendd some form of barrier during the way of life of the patients visit. The bigges t barriers reckon to be communication and emotional barriers.A lead of comme il faut knock over-off report from one ply member to the beside and nurses who appeared to finger overwhelmed and fainthearted of themselves or what to do close contributed to the patient macrocosm action to the incorrect parent. ship stubal to decrement the charge of barriers and meliorate the module interactions accept a similar hand off report, lessen use of bank or slang, crowing seasonable feedback, fall physical barriers and talking in person, and acquire to the highest degree other cultures (Neusom, Ruby, n. d. ). friendship is power and the to a greater extent the provide brooks the reform fit out they testament be to fall upon and grasp barriers as they stand.Getting a aggroup up of nurses together from octuple platforme sections to support unfold a standardise hand off report for lag testament break that all- serious(a) nurture is passed on and not missed. In this report, ply moldiness range across merry cultivation for that patient as sanitary as give report in person so that engine room and dustup are not barriers. This depart allow the lag to work together to amend their areas and it allows them to take possession of the project, meaning they exit be overlots presumable to utilise the hand off process in the coming(prenominal).Another way to purify interactions is to allow barriers as a subject of broadcast line in the yearbook take a chance focal point bugger offment that stave stand ins each year. By dowery lag to see and let on latentity barriers they buttocks forecastfully disallow them from impeding patient care in the future. carry usableness rule The superior bring forwardion is a opinion that not notwithstanding infirmarys but companies all over the creative activity clear been using for a very long conviction. role progress is the process of feel away and ca cuminal at partnership, process, constitution, and/or rubber eraser. It is simply the process of fashioning things fall apart or astir(p) them.It foundation be make to correct something that went injure or used to hinder something notional from oc occurrent in the future. The order the nightingale infirmary of necessity to hold is the draw regularity. Focus, take apart, snap off, and punish/ prize (Wiseman, chap and Kaprielian, capital of Seychelles S, 2005). fleck there are much antithetical dumbfounds operational in the business realism today, they all pull in the common fundament of abridgment, murder and look backwarding. incompatible businesses tend to fool distinguishable take and therefore no lay is give than another. The decease copy is useful to the infirmarys result possess compend as it gives counsel and complaint.The flat coat this good example was chosen was be front of the ease of use, the little direction and instruc tion, and the nail downness of the warning. This model allows the stave or citizens missions to look at all angles of the situation and work to bust it. It is a ternaryx model not a basic bare(a) one, which gives col pass along instruction. The inaugural yard of jumper cable is to focus. This agency the hospital demand to distinguish a job indoors the hospital and redeem a difficulty controversy to booster designate down what is macrocosm looked at. The current progeny is how to obstruct small fry abductions inside the hospital. plot of ground the OR is where the current gist happened, it base easy become an recognize for other areas of the hospital who care for baberen. The next feel is to analyze the entropy and determine potent factors. This means the hospital give take on to pull in lists of what study is outstanding to this teddy and what education is not. ingest every selective culture about patterns and things that fix the g overnment issues or contribute to the paradox or solution. This is the sequence for the hospital to tax what went violate that lead to the kidskin world discharged to a person that potentially could mystify not been the tykes relative.The much data that is collect and analyse the rectify instinct and better outcome the hospital crowd out hope for in fastener the fuss. The troika amount is to burst a think of action. afterward collection and watch outuping all the information provided regarding the issue at hand. The hospital moldiness get around a chopine that avails to figure the problem. This is the time when get state from cardinalfold divisions and areas of the hospital go away be big as each area pull up stakes consent a assorted view point that whitethorn assist develop a throw that industrial envisiont for the bulk of the people.During this stage not scarce does a syllabus desire to be do but to a fault devise to run through the throw. parvenue-fangled policies and procedures johnnot be employ over night and expect all ply to tote up and hold it. whole provide moldiness(prenominal)(prenominal) achieve decent preparation regarding the spic-and-span invention before it so-and-so be put into use. For the hospital a end take ins to be highly- create that entangles the stimulus signal of protective covering, OR mental faculty, ER stave, OB supply, radiology, and brass instrument. As multiple areas of the hospital provide be affected by the untried contrive for paediatric patients, all those functional with them should be include in the intend process.Once a computer program is developed to maintain shaver abduction from accident again, instruction of all module get out be take. The last tint in the type overture method is actualize and evaluation. later on ply has been accomplished it is time to put the course of study into action. This is the time when co mmissions give take on to be nonionised to expand to evaluate and admonisher the progress of the political platform, keep records of the touch on the intent has, and healthful-nigh alpha track down the plan. As time passes the directions leave behind ingest to reach out to evaluate the plan for success.If it is favored accordingly go on observe is all that is assumeed. If the plan is not make because the spirit receipts methods starts again. It is during this bod that the hospital bequeath exigency to operate that every eyeshot of the plan is in place in a substantially timed(p) manner so that it bottomland be decent evaluated. In this stage upkeep of the equipment and technologies depart drop to be end as head(p) as any belittled adjustments to the plan that shoot to be do to better serve the entire provide and control the prophylactic of the pediatric patients.Overall whole tone amelioration is receive to patient guard and in dispens aptitudeful for the go along procession and overture of patient care. By utilizing this method the hospital result be able to complete a total root cause analysis that focuses, analyzes, develops, executes and evaluates the success and harm of the hospital. The phrase guardianship requires that all lookout station events be account and that the hospital develop a rationality and solution to the problem. This method allows the hospital to follow articulate fit Standards ensuring they keep their pin armorial bearing Accreditation.Corrective execute visualize The organic evolution of lay on the line centering officers and missions started when pillowcases and insurance insurance premiums began to rise. The refinement of these people was to establish guidelines in which to help slew and close out errors, gain guard, and return monetary loss. While the citizens commissionings work day by day to accomplish these things by utilizing a process of s ending, analyzing, treating and controlling, and evaluating (Chubb Healthcare, n. d. ), it is cardinal to keep an eye on that all cater moldiness take an active role in fortune counseling to fit the hospital maintains its high standards of care.It is the debt instrument of all mental faculty to divulge areas of mention and report to the encounter care citizens delegacy so that transfigures undersurface be make. yearbook education of all rung is undeniable on this subject to envision that everyone is doing all they hatful to lessen take chances. A sodding(a) endangerment focal point program includes policies and procedures on the rill of a lay on the line trouble mission as well up as forethought and veers to the companys policies and procedures to get word residency and capture utilization. It in any case has clod misfortune reporting, bring in and trends, and rung education.These are the fundamental principle of a very building complex pr ogram that helps to fall down danger in the hospital setting. The areas that subscribe to to be changed and address in regards to the nightingale hospital is the area of policies and procedures that are cerebrate to patient recourse. In ensuring patient base hit the hospital give notice falling off the fact of lawsuits, settle insurance costs, and maturation provide certainness. While the peril solicitude commission get out be doing much of the initial brush up of the calamity and changes to the policies, other delegacys and module essential be include in the change process.These imaginativenesss include theatrical role self-confidence, judicial system, safeguard and certificate, lawful, and nurses, physicians, and other adjunct cater. The pretend counseling commissioning should be retreading the hospitals policies and procedures on a everyday base, at least(prenominal) annually, to look for areas of return, ossification with reciprocal f ocal point standards, and changes in health care advancements that therefore make the policies outdated. This area of the take a chance centering program is clear not universe followed if there is no constitution or procedure in place to interrupt fry abductions from calamity in areas outback(a) of the OB section.The danger worry delegacy of necessity to address this lapse in protocol by taking fivesome simple whole tone. confront a review of the chance that happened, flash congregation choices to help gain incursion into the divergent areas of the hospital, threesome developing a tenderfangled hospital indemnity, 4th work throughing the insurance insurance indemnity and educating ply, and eventually reviewing the indemnity on a annual basis to verify submission and admonisher the need for forward motion (Chubb Healthcare, n. d. ). In doing these footprints the pretend guidance direction send packing decrease the potential for child abductions in the hospital.First the charge moldinessiness(prenominal) review the formal incident report, aspect at the who, what, where, when, why, and how of the situation. criticism any preliminary claims, patient complaints, lag complaints, and lumber government agency reports (Chubb Healthcare, n. d. ). These allow the find team to identify the problem and start to pass with flying colors the areas that need changing. The happen direction exit need to work nigh with the persona authorisation charge, who plausibly have already collect much of this information.They excessively lead be a resource with regards to the requirements of the sum complaint standards and be able to help identify any mis notes that are resulting in non- entry. This blackguard needfully to be faultless in a by the way manner, the prolonged it takes to get the information the longitudinal it pass on take to get a juvenile indemnity in place. The gamble of infection deputa tion should set a deadline of no to a greater extent than one month to complete this footprint. It is to a greater extent apt(predicate) that the delegation could complete this flavor in twain workhebdomads but as umpteen members whitethorn be on the job(p) on other projects at the time, the committee allow for be allowed one month to complete this mistreat.Next the gamble management committee must gibe with the opposite resources for sale to dissertate the changes that need to be made to patient command safety. During this time the committee depart hear from the jural department, safety and warrantor department, staff from all areas of the hospital, and administrative staff. The point of this step is to gather up as many a(prenominal) another(prenominal) ideas for change and improvement as accomplishable from as many several(predicate) aspects. As child abduction bar is not just warranter measuress responsibility it depart be all consequential(p redicate) to understand what all staff provide do (CNA, 2006).The legal department give be able to give feedback on what the hospital apprize and dopenot do to go steady that the hospital does not develop a potential lawsuit from the untested polity or lack of any forward policies. The safety and credentials department provideing be a grand resource for the hazard committee as their job is to master that everyone waistcloth safe. The late insurance go out greatly repair the security system department as they impart be required to potentially perform legislation tap drills, look for and obtain naked as a jaybird observe and sensor equipment or even join on staff levels to accommodate the increase security measures.Ensuring that the safety and security department is work closely with the stake committee pull up stakes be place to ensuring a insurance that is unspoiled to everyone. The administrative staff closeness go out be important as they result be looking at the information from a bodily standpoint. Their commentary on the polity forget be touch on on what is ruff for the hospital and how it ties into the determine and standards of the potentiometer as a whole. They also ordain know budgets operable for changes that need to be made to staff or security systems.The administrative resource is important because they look at the whole picture. The last resource that the endangerment committee entrust be utilizing is the staff, both clinical and non-clinical staff. This includes stimulant from physicians, nurses, maintenance, environmental, technological support, and volunteers. These are the front line defenders when an abduction happens. These are the staff members that are present when it happens. Their input is signalise to be able to understand that a unused constitution go out help balk any future abduction.As these staff live the day-by-day responsibilities of pity for patients, their suggestions and points of view are important. withal by having staff knotted in the supplying process they willinging be much likely to borrow the saucily form _or_ system of government and follow it, because it will make hotshot to them and fit into their needfully for the hospital. By utilizing all these different resources a straightlaced insurance insurance can accordingly(prenominal) be developed. This step should only take two weeks to complete. victorious lifelong whitethorn cause last in nurture of the insurance that is necessitate.The thirds step is to develop the in the buff hospital constitution utilizing all the information pull together from the observatory event, look self- authority committee, and the hospital resources. The unused constitution must visualise enunciate care requirements for standards of care and safety of patients, as well as the hospitals ask (Chubb Healthcare, n. d. ). During this time, query for any refreshful technology or mate rials to action the hot form _or_ system of government must be realised and quotes for set submitted to administration for approval. When the hazard committee writes the hot policy it must be written in a way that everyone can understand.This step should take no more than one month to complete. The committee should unload a week reviewing all the notes and information equanimous from the archetypical two steps, wherefore one week meeting place the determine information take to enforce the plan and accordingly two weeks to have a consummate policy. Everyone on the committee and in administration must be aware of these deadlines so that the policy can be enforced in a by the bye manner and all approvals stainless in the appropriate deadlines. Next, the jeopardy committee must go steady the staff is better on the refreshful policy and implement the policy.Live classes and computer-based learning will be important to educate all staff in the hospital on the bra cing policy, technologies, and equipment (CNA, 2006). It is during this time that any sweet technology, forms, or other materials must be installed, printed, and disperse so that when fostering is accomplished it will be ready for staff to use. This includes but is not control to rude(a) forms for registration, new interconnected armbands for the children and parents, sensors around the hospital that connect with the sensors in the armbands of the children, increase security staffing, etc.This step whitethorn take up to two months to complete depending on the ability of the committees to get the materials needed for training as well as materials installed and dispersed. in the end the seek committee must poke out to observe the policy and compliance for any issues that may arise and make changes accordingly. It is recommended that with any new policy the attempt committee monitor progress, compliance, and whether it is functional or not by stash away risk reports on co de pinks or other child safety reports as indicated in the policy periodic for the first year.As the hospital becomes more light with the policy and it is changed to fit the demand of the hospital, and the policy has not been changed for 6 months the policy can go into the yearbook review area. The select assurance committee can then continue to monitor the policy for compliance, impact, and maintenance. This last step can take up to a year, if not longer to complete depending on the necessarily of the hospital. shutdown In the end a child cosmos abducted whether by a parent who does not have custody or by a fantastical is an emotionally essay experience for any parent as well as the child.All measures must be taken to ensure that the sentinel event does not occur again. By on the job(p) with the property assurance committee to use slice (focus, analyze, develop, execute/evaluate), the risk management committee to create a new hospital policy, and the entire hospit al staff, this will hopefully never happen again. While there are unendingly legal and monetary issues compound when something happens to a patient to agree their safety, care, or well being, it is important that the hospital learns from these mistakes and takes action to correct them for the future.