Patient Safety and Quality Improvement
 Modules  Module 7: Adverse Patient Outcomes
1. Introduction to Course
2. History of Patient Safety
3. The Science of Human Error
4. The Analysis of Medical Error
5. Evidence-Based Medical Practice
6. Communication and Information Transfer
7. Adverse Patient Outcomes
8. The Role of the Patient and Family
9. Environmental Safety in the Medical Setting
10. Safe Medical Practice In Ambulatory Settings

Sentinel Event

  • JCAHO defines a Sentinel Event as an event that results “in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition or the event is one of the following (even if the outcome was not death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition):
    • Suicide of any individual receiving care, treatment or services in a staffed round-the-clock setting or within 72 hours of discharge
    • Unanticipated death of a full term infant
    • Abduction of any individual receiving care, treatment or services
    • Discharge of an infant to the wrong family
    • Rape
    • Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
    • Surgery on the wrong patient or wrong body part
 
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