Homework on Nursing Elective 2

Submitted to: Mrs. Marilyn D. Junsay

Submitted By: Flores Baltazar Suelo Genciana Antonio Memoracion Alba Noviza (Group 4)

February 14, 2013

Clinical Pathways were introduced in the early 1990s in the UK and the USA, and are being increasingly used throughout the developed world. Clinical Pathways are structured, multidisplinary plans of care designed to support the implementation of clinical guidelines and protocols. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc.), with a specific condition over a given time period, and include progress and outcomes details. Clinical Pathways aim to improve, in particular, the continuity and coordination of care across different disciplines and sectors. Care Pathways can be viewed as care plans because they define the care to be provided for a given patient or patient group for a given condition in a step-wise sequence. Pathways may also include clinical algorithms or flow charts of the clinical decisions to be made. Clinical Pathways have four main components (Hill, 1994, Hill 1998): a timeline, the categories of care or activities and their interventions, intermediate and long term outcome criteria, and the variance record (to allow deviations to be documented and analyzed).

Clinical Pathways differ from practice guidelines, protocols and algorithms as they are utilized by a multidisciplinary team and have a focus on the quality and co-ordination of care.1 Pathways support the integration of evidence-based practices medicine and use of clinical guidelines. Yet they are not prescriptive and do not override clinical judgment. They improve clinical effectiveness, risk management and clinical audit and enhance multidisciplinary communication, teamwork and care planning. They also help reduce unjustified variations in patient care (by promoting standardization)2. They help improve and even reduce patient documentation and optimize the use of resources. Clinical Pathways are also called Integrated Care Pathways, Multidisciplinary pathways of care, Pathways of Care, Care Maps, Collaborative Care Pathways. What are the clinical pathways used in TMC? The following is a partial list of clinical pathways that have been developed by Medical City: 1. Symptomatic cholelithiasis in adults 2. Acute gastroenteritis in adults 3. Urinary tract infections in pediatric patients 4. Severe risk community-acquired pneumonia in adults 5. Possible Ischemic chest pain 6. Non-ST elevation myocardial infarction unstable angina 7. Possible acute coronary syndrome 8. ST elevation MI fibrinolysis 9. ST elevation MI percutaneous coronary intervention 10. Normal spontaneous delivery 11. Acute gastroenteritis in pediatric patients 12. Pediatric community-acquired pneumonia 13. Sepsis alert 14. Leptospirors 15. CABG 16. Acute appendicitis in adults 17. Dengue in adults 18. Dengue in pediatric patients 19. Elective CS 20. Bronchial asthma in adults 21. Long bone fracture 22. Systemic viral infection 23. Deep vein thrombosis prophylaxis 24. Stroke 25. Deep vein thrombosis

How are pathways developed in TMC? Any staff member can propose a pathway for a specific condition. The Pathways and Guidelines Committee of the hospital supports pathway teams throughout the stages in pathway development, namely: 1. Convene the pathway team 2. Write/draft the pathway or adapt the pathway if already available elsewhere 3. Approve the pathway 4. Pilot test the pathway 5. Disseminate and promote the use of pathway 6. Review the pathway at least once a year and revise as appropriate The quality of the pathway content as well as the processes of development, implementation and maintenance are evaluated using the Integrated Care Pathway Appraisal Tool (ICPAT). Parts of a Clinical Pathway TMC clinical pathways have a standard format and content. At the top of the page, the pathway title indicates the clinical condition and population covered by the pathway, for example, Dengue fever in children. Below the title are the inclusion and exclusion criteria which defines the specific signs, symptoms or clinical impressions that will include or exclude patients from the pathway. On the left hand side of the pathway is the column for Providers Notes. This must be filled out by doctors and other allied medical staff in SOAP format (i.e., S for subjective complaints/symptoms; O for objective physical and laboratory findings; A for assessment/ working diagnosis/ clinical impression; P for plan of care (diagnostic, therapeutic, rehabilitative, others). On the right hand side are the Orders, covering the following care elements: 1. Assessment and Monitoring (vital signs, hemodynamic monitoring, etc) 2. Laboratory tests and diagnostic procedures 3. Treatments (medical and nursing procedures) 4. Medications, IV fluids and blood transfusions; medication reconciliation 5. Nutrition (enteral and parenteral feedings, diet and fluid restrictions, supplemental feedings) 6. Activity/Safety (allowed degree of ambulation, toileting, fall prevention protocol) 7. Consults and team communication (referrals to other specialists or units; scheduling of team conferences) 8. Psychosocial counselling (assurance and comfort provided to patients and families) 9. Patient/family education and communication (standard education about medications, diet, device use, rehab techniques, self-care; reference to Patient and Family Education Form, family conferences, orders for translation and other communication aids) 10. Discharge Planning (assessment of patient outcomes that must be achieved prior to discharge, orders for self-care and post-discharge referrals) How are pathways used in TMC? The pathway is a permanent part of the patients medical record. The Nurse in Charge and Attending Physician activate the appropriate pathway on admission or when the interval of care begins. Both NIC and AP must sign at the bottom of the pathway form to activate it. Generally, pathways must be activated daily; authorization to carry out the orders lapse after the time interval covered by the pathway. The care delivered and patient outcomes must be measured against those pre-specified in the pathway. The pathway should be used during Nursing shift endorsement Bedside rounds Chart rounds All care team members must review the problem list, variances and outcomes daily.

What are the roles of the clinical staff in pathway use? Doctors Attending physicians or their authorized residents must activate pathways daily by signing at the bottom. Because the pathway contains pre-printed orders, APs must use pathways in lieu of order sheets. This saves time and paper. It also allows the staff to anticipate what APs will likely order. If the AP wishes to write non-pathway orders, she may do so using the standard order sheet. There are two types of orders. Mandatory orders are those which are applicable to 100% of the population. Activation of the pathway will result in carrying out these orders. Bullets () mark these orders. If for any reason a mandatory order is deemed not applicable a single line may be drawn across the order and initialed by the MD. Optional orders are those that do not mark () should be placed by the MD in the box to indicate the selection of the order to meet the individual needs of the patient. If the box is left empty, the order is deemed not required. Nurses Nurses in charge must assist APs in selecting and activating the appropriate pathway daily. When the AP activates the pathway by signing at the bottom line, the nurse must review and initial to acknowledge the orders. The NIC does all mandatory observations that are not cancelled and all optional interventions that are ticked. Whenever an intervention is accomplished, the nurse in charge writes his / her initials and the time the order was done on the appropriate Sign column. Other care team members Therapists, nutritionists, interns, and clerks carry out all mandatory orders pertaining to them that are not cancelled and all optional orders that are ticked. Whenever an order is accomplished, they must write their initials and the time the order was done on the appropriate shift column (AM/PM/evening). Reviewing outcomes: All MDs and nurses must review the patients progress against intermediate and discharge outcomes on a daily basis. They must also revise their care plan if justified by the review of patients outcomes. The NIC must review variances daily and report them to the AP and the rest of the care team. The NIC must ensure that all variances result in re-evaluation of plan of care by appropriate disciplines. If an outcome is not met, a variance code is written on the variance column and initials are placed in the column. The code indicates the explanation for the variance as provided in the progress notes or on the pathway itself. The note should include the identified problem, actions taken or plan for follow-up. Adjusting the interventions If an outcome is not met within the expected time frame, the interventions should be revised, when necessary, to ensure the outcome is met in the next time frame and/or as soon as feasible. Discontinuing the pathway The pathway will be discontinued whenever: 1. The patients primary diagnosis changes 2. The patients condition significantly worsens 3. The patient fails to meet clinical outcomes for 24-48 hours

To discontinue the pathway, an order to discontinue the pathway is written on the standard Order sheet and a SOAP note is written by the MD outlining the patients new plan of care and new orders. A new nursing plan of care is also written. The pathway is then filed in the patient record. Reference: The Medical City. (2011). Clinical Pathways. Retrieved February 13, 2013 from http://search.yahoo.com/search;_ylt=A0oGdXSfnhtRjHkA17ZXNyoA

The OASIS In home health, the Oasis (Outcome and Assessment Information Set) is done on admit, resume care, recertifications, significant changes and on discharge. From the admit and the recert OASIS is created the physicians Plan of Care called the 485. This is the tool that must be used at every home health visit when completing your nurses note. This is your physician order for care delivered in the home. Your documentation must show that you are aware of the physician orders, are following the physician orders and that you are updating the physician, the patient and the family on all changes related to the patient that are not on the physician orders. Without the 485, you are going blind into a patients home and delivering care without any idea of what the physician is expecting you to do and to know. That is not the way you want to deliver your professional care! In order for the office staff to generate that hard copy of your physician order, the 485, you must get the OASIS, especially the admit but all types of this tool, completed and turned into your office within a timely fashion. Every home health office has different expectations, however, most are expecting that OASIS to be returned to the office within a 24 hour window. Reference: Hubpages. (2011). Documentation Basics for Home Health. Retrieved 2/13/13 from http://rnmsn.hubpages.com/hub/Documentation-Basics-for-Home-Health

Magnet status is an award given by the American Nurses' Credentialing Center (ANCC), an affiliate of the American Nurses Association, to hospitals that satisfy a set of criteria designed to measure the strength and quality of their nursing. Reference: Summers, S. (2012). Magnet status: What it is, what it is not, and what it could be. Retrieved 2/13/13 from http://www.truthaboutnursing.org/faq/magnet.html#ixzz2Kmofk1Ko Magnet status is the highest national recognition awarded to a hospital or medical center for excellence in nursing. It is accepted nationally as the gold standard of patient care and provides health care consumers with a benchmark to measure quality of nursing care. Reference: Cleveland clinic. (2013). Magnet status. Retrieved 2/136/13 from http://my.clevelandclinic.org/Documents/nursing/magnetBrochure.pdf

A Magnet hospital is stated to be one where nursing delivers excellent patient outcomes, where nurses have a high level of job satisfaction, and where there is a low staff nurse turnover rate and appropriate grievance resolution. Magnet status is also said to indicate nursing

involvement in data collection and decision-making in patient care delivery. The idea is that Magnet nursing leaders value staff nurses, involve them in shaping research-based nursing practice, and encourage and reward them for advancing in nursing practice. Magnet hospitals are supposed to have open communication between nurses and other members of the health care team, and an appropriate personnel mix to attain the best patient outcomes and staff work environment. Reference: Summers, S. (2012). Magnet status: What it is, what it is not, and what it could be. Retrieved last 2/13/13 from http://www.truthaboutnursing.org/faq/magnet.html#ixzz2Kmofk1Ko

Variance reporting analysis A variance is any mandatory or checked optional intervention that was not done. an abnormal finding An unmet outcome within the time frame Variances may be noted by any care team member.

Variance analysis Is a critical part of developing and using integrated care pathways. I It is used to measure what happens to the patient on the pathway, whether they deviate from the expected pathway and if so, for what reasons. The resulting analysis can be used to amend the integrated care pathway itself (if, for the majority of patients, the practice is different to the pathway) or the processes followed (if a certain task is persistently not met or not met at the expected time). Where available, variance analysis is displayed with the pathway document.

How to analyze variances 1. Identify critical pathway orders. These are the orders which, if not carried, will significantly put the patient at risk for harm. 2. Using the variance monitoring form, count the number of variances that occurred in the critical pathway orders. 3. Perform RCA to determine causes of variances. 4. Pilot test countermeasures. 5. Monitor variance counts and note if they decrease over time. References: Integrated care pathyways. (2007). Retrieved February 13, 2013, from Great Osmond Sreet Hospital for Children: http://www.gosh.nhs.uk/health-professionals/integrated-carepathways/ Parsley, K. (1999). Quality Improvement in Healthcare: Putting Evidence into Practice (2nd Ed. ). United Kingdom: CORRIGAN Philomena Publication.

Nursing audit, is a review of the patient record designed to identify, examine, or verify the performance of certain specified aspects of nursing care by using established criteria. Nursing audit is the process of collecting information from nursing reports and other documented evidence about patient care and assessing the quality of care by the use of quality assurance programmes. Nursing audit is a detailed review and evaluation of selected clinical records by qualified professional personnel for evaluating quality of nursing care. A concurrent nursing audit is performed during ongoing nursing care. A retrospective nursing audit is performed after discharge from the care facility, using the patient's record. According to Elison "Nursing audit refers to assessment of the quality of clinical nursing". According to Goster Walfer a. Nursing Audit is an exercise to find out whether good nursing practices are followed. b. The audit is a means by which nurses themselves can define standards from their point of view and describe the actual practice of nursing. Nursing audit is defined as: .part of the cycle of quality assurance. It incorporates the systematic and critical analysis by nurses, midwives and health visitors, in conjunction with other staff, of the planning, delivery and evaluation of nursing and midwifery care, in terms of their use of resources and the outcomes for patients/clients, and introduces appropriate change in response to that analysis (NHS ME, 1991 Framework for Audit for Nursing Services). Purposes of Nursing Audit 1. Evaluating Nursing care given, 2. Achieves deserved and feasible quality of nursing care, 3. Stimulant to better records, 4. Focuses on care provided and not on care provider, 5. Contributes to research. Audit as a Tool for Quality Control An audit is a systematic and official examination of a record, process or account to evaluate performance. Auditing in health care organization provide managers with a means of applying control process to determine the quality of service rendered. Nursing audit is the process of analyzing data about the nursing process of patient outcomes to evaluate the effectiveness of nursing interventions. The audits most frequently used in quality control include outcome, process and structure audits. Advantages of Nursing Audit : Can be used as a method of measurement in all areas of nursing. Seven functions are easily understood,

Scoring system is fairly simple, Results easily understood, Assesses the work of all those involved in recording care, May be a useful tool as part of a quality assurance programme in areas where accurate records of care are kept.

Disadvantages of the Nursing Audit : appraises the outcomes of the nursing process, so it is not so useful in areas where the nursing process has not been implemented, many of the components overlap making analysis difficult, is time consuming, requires a team of trained auditors, deals with a large amount of information, only evaluates record keeping. It only serves to improve documentation, not nursing care

Reference: Current nursing. (2010). Nursing audit. Retrieved 2/13/13 from http://currentnursing.com/nursing_management/nursing_audit.html

Sentinel Events Monitoring Sentinel Events are defined as serious adverse events that cause death or severe injury to the patient and result in loss of trust in the national healthcare system by citizens. The surveillance of sentinel events which has been well under way in other countries is an important role of public health. It is an indispensible tool for the prevention of such events and for the promotion of patient safety. DESCRIPTIVE FORMS OF SENTINEL EVENTS Sentinel Event No. 1 Procedure Performed on Wrong Patient Description Performing surgical or invasive procedures on a patient other than the one needing surgery. Includes all surgical interventions or invasive procedures (e.g. interventional radiology), performed in emergency, outpatient and inpatient requiring hospitalization/ admission (ordinary and day surgery) and outpatient, regardless of the complexity of health services. Excludes nonsurgical procedures. Rationale The event highlights the possible organizational shortcomings, such as the lack or inadequate implementation of specific procedures and/or insufficient communication between operators or between operators and patients/families. In particular, the event may be due to compilation error, transfer and/or exchange of clinical documentation, the improper application of information to the patient assisted person and their family members. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training.

Sentinel Event No. 2 Procedure Performed on Wrong Body Part (side, organ or part) Description Performing a surgical procedure on the correct patient, but on the wrong side, organ or body part. Includes all surgical procedures performed in emergency, requiring hospitalization (ordinary and day surgery) and outpatient, regardless of the complexity of the health service. Rationale The event highlights the possible organizational shortcomings, such as the lack or inadequate implementation of specific procedures and / or insufficient communication between operators or between operators and patients / families. In particular, the event may be due to compilation error, transfer and / or exchange of clinical documentation, the improper application of information to the patient and their family members. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 3 Wrong Procedure performed on correct patient Description Performing a diagnostic procedure/therapy other than that prescribed. Rationale The event highlights the possible organizational shortcomings, such as the lack or inadequate implementation of specific procedures and / or insufficient communication between operators or between operators and patients / families. In particular, the event may be due to compilation error, transfer and / or exchange of clinical documentation, the improper application of information to the patient person and their family members. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 4 Retention of instruments or other foreign objects during surgery requiring another or successive surgery or procedure performed to rectify error Description Instrument or other material left within the surgical site during a surgery that requires a subsequent intervention. Covers all surgical instruments, gauze, suture needles, instrumentation items including screws, pieces of needles deriving from local anaesthesia, surgical drainage of debris and other material connected with the execution of surgery, but not intentionally left in the surgical site. Rationale The event highlights the possible organizational shortcomings, such as the lack or inadequate implementation of specific procedures and / or insufficient communication between operators or between operators and patients/families. In particular, the event may be due to lack of or inadequate implementation of procedures for counting surgical instruments or other material. . The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training.

Sentinel Event No. 5 Transfusion Reaction consequent to AB0 incompatibility Description Transfusion reactions caused by AB0 incompatibility. Included are all transfusion reactions by AB0 incompatibility, regardless of the severity of the damage. Rationale The event highlights possible shortcomings in the organizational management of different stages of the transfusion process from sample for blood group typing of the recipient, to the transfusion of blood components and / or inadequate communication between operators or between operators and patients / family. In particular, the event may be due to incorrect compilation, transfer and exchange of clinical documentation, difficulty in understanding the request, exchange of tubes or blood bags, inattention by health professionals. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 6 Death, Coma or Severe Harm Caused by Errors in Pharmacological Therapy Description Death, coma, physiological alterations and any other serious damage resulting from errors during the course of drug treatment in medical facilities. Anaphylactic shock in a patient with a known history of allergy to the drug that was administered and which caused the reaction. Exclusions: Adverse drug reactions, side effects or other effects not determined by errors. Rationale The event highlights the possible organizational shortcomings such as the lack or inadequate implementation of specific procedures and/or insufficient communication between operators or between operators and patients/families, as well as improper training. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 7 Maternal Death or Severe Illness related to Labour and/or Childbirth Description Maternal death or serious illness related to labour (spontaneous or induced) and or childbirth and puerperium Rationale The event highlights potential organizational deficiencies, such as the lack of care procedures, the underestimation of risk factors, insufficient communication amongst operators and amongst operators and patients/families. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training.

Sentinel Event No. 8 Death or Permanent Disability in healthy newborns weighing > 2500 grams, not related to congenital illness Description Death or serious medical condition, which may result in permanent disability, in healthy babies weighing > 2500 grams, not suffering from congenital diseases or other pathologies incompatible with life. Rationale The event highlights potential organizational deficiencies, such as the lack of care procedures, the underestimation of risk factors, insufficient communication amoung operators and amoung operators and patients/families. In particular, the event may be due to therapeutic delays / omissions care during childbirth or peri natal life. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 9 Death or Severe Injury due to Patient Fall Description Death or serious injury caused by patient fall in health facilities. This list includes only falls that cause death or serious injury. Rationale The event highlights the possible organizational shortcomings, such as the lack or inadequate implementation of specific procedures and/or insufficient communication between operators or amoung operators and patients/families. In particular, the event may be due to underestimation of the risk factors related to patients (e.g. age, previous falls, taking certain medications, cognitive deficits, associated disorders, footwear, inadequate clothing) or risk factors related to the environment (e.g. slippery floors, unsafe stairwells, lack of lighting, lack of support points). The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 10 Patient Suicide or Attempted Suicide in a Hospital Description Death by suicide or attempted suicide within a healthcare facility, including also Mental Health Outpatient Services. Rationale The event highlights the possible organizational shortcomings, such as the lack or inadequate implementation of specific procedures and/or insufficient communication amoung operators or amoung operators and patients/families. In particular, the event may be due to the lack of appropriate procedures to take charge of the patient, the underestimation of the mental state of the patient, inadequate supervision of patients at risk, a non-compliant suitable environment. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training.

Sentinel Event No. 11 Violent Acts to Hospitalized Patient Description Any type of violence (on account or omission) to patient committed by anyone (healthcare professional, another patient, family, visitor) in health care facilities. Rationale The event highlights the possible organizational shortcomings such as the lack or inadequate implementation of specific procedures and/or insufficient communication amoung operators or amoung operators and patients/families and may indicate a lack of awareness of the organization of the possible dangers of aggression within healthcare facilities. In particular, the event may be due to lack of vigilance, possible stress and burn-out of personnel, and lack of information and training. The recognition of the event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 12 Acts of Violence Sustained by Healthcare Workers Description Violence acts against healthcare worker in healthcare facilities committed by: patients, their relatives or caregivers, and visitors. Rationale The event highlights the possible organizational weaknesses and may indicate insufficient awareness of the organization of the possible danger of violence in healthcare facilities. In particular, the event may be due to lack of vigilance, underestimation of patients at risk of making physical attacks, relationship difficulties between operators and users. The recognition of the event is important to proceed with the definition of interventions in organizational and logistical support, for the revision of the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 13 Death or severe harm consequent to a malfunction of the transport system (intrahospital, extrahospital) Description Patient death or serious injury resulting from failure of the inpatient-or outpatient,(intrahospital or extrahospital)transport system, both of the emergency-urgent care 118 and scheduled appointments. All transport system malfunctions/ failures are included, intra-hospital and outpatient, whether land, air or sea, involving adults or paediatric-neonatal patients, resulting in death or serious harm to the patient because of the occurrence of one or more of the following situations : failure or untimely arrival to location by means of assistance, expedition of inappropriate form of transport in relation to the emergency involved or in relation to geographical area or in relation to local weather conditions, interruption or delay in transportation due to sudden mechanical failure, sending an inappropriate means of transport lacking appropriate medications/pharmaceuticals, medical devices and / or specific emergency treatment devices, or presence of unskilled or unfit medical personnel for the kind of emergency involved. Rationale The occurrence of the event indicates a lack of organization or logistics of the transport system which may concern or involve the training of personnel, agreement and effort of health

professionals involved in assessment protocols and transfer of patients, the operational coordination and pre-transport system communication, periodic maintenance of vehicles both in terms of mechanical efficiency as well as kits and devices for emergency treatment, the use of transport resources under safety conditions. The recognition of the event is important in order to proceed with the definition of interventions in organizational and logistical support for the revision of the protocols in use, to start continuous education programs and personnel training. Sentinel Event No. 14 Death or Severe Harm Consequent to an Incorrect Triage Code Application in the Central Operative Unit 118 and/or in First Aid Description Patient death or serious injury resulting from incorrect assignment of the severity code following a triage code application at the event, on emergency vehicles, in the Operations Centre 118, and inside the emergency room of a hospital. Includes all patients who were assigned by staff members responsible for code application, an underestimated severity code compared to the actual clinical severity resulting in death or serious harm as a result of the failure or delay in medical intervention or sending the patient to an inappropriate diagnostic-therapeutic pathway. Exclusions: patients in whom the erroneous attribution of triage code does not affect the timeliness of medical intervention and does not produce adverse effects to the patient because the results of the underestimation in delayed timing and type of intervention is not relevant to the outcome. Rationale The occurrence of the event indicates a malfunction of the triage system because of a lack of knowledge sharing and protocols by the staff involved or due to poor local adaptation of the protocols used at the facility or inadequate training and education of the assigned staff nurses. The recognition of the event is important to undertake an audit of triage protocols or to start continuous education programs and personnel training activities. Sentinel Event No. 15 Unexpected Death and/or Severe Harm Consequent to a Surgical Procedure Description Unexpected death or serious injury resulting in surgery, regardless of the complexity of the intervention. Exclusions: all adverse events resulting from the patients clinical condition and attributed to the associated intrinsic risk. Rationale The event highlights the possible organizational shortcomings such as lack or inadequate implementation of specific procedures and guidelines for safety in the surgical route, insufficient communication amoung operators or amoung operators and patients / families, inadequate personnel management, poor education and training, inadequate supervision of operators. The recognition of this event is important to proceed with the definition of interventions in terms of organization, to review the protocols in use, to start a training activity and training of personnel.

Sentinel Event No. 16 Every other adverse event that causes death or severe harm to the patient Description All other adverse events due to errors and/or substandard care (assistance levels lower than the expected standards), not included in the 15 sentinel events as previously described which causes death or serious harm to the patient. Rationale The occurrence of the event is indicative of possible organizational weaknesses, insufficient or inadequate training of operators, lack of communication amongst workers, factors that determine a loss of public confidence/trust towards the NHS. The recognition of this event is important to proceed with the definition of interventions in terms of organization and logistical support, for the revision of the protocols in use, to start a training activity and training of personnel. Reference: Ministry of health. (2009). Sentinel Events National Observatory. Retrieved February 13, 2013 from http://www.salute.gov.it/qualita/paginaDettaglioQualita.jsp?menu=centres&lingua=englis h&id=1639

Credentialing Credentialing (or medical credentialing or "provider credentialing") is the process of establishing the qualifications of licensedprofessionals, organizational members or organizations, and assessing their background and legitimacy. Many health care institutions and provider networks conduct their own credentialing, generally through a credentialing specialist or electronic service, with review by a medical staff or credentialing committee. It may include granting and reviewing specific clinical privileges, and medical or allied health staff membership. Medical Credentialing Medical Credentialing (Provider Credentialing or "Getting on Insurance Panels") is the process of becoming affiliated with insurance companies so that you (the medical provider) can accept third party reimbursement. While just a few years ago health professionals considered medical credentialing optional for building a practice, today it has become more necessary than ever for providers to be networked with insurance companies. In part, this is because more persons/patients in the USA have health insurance than ever before, and because patients desire (even demand) to use their health insurance when seeking out health care services (in lieu of out-of-pocket payment).[1] In addition, medical credentialing is becoming more important as health insurance plans are becoming broader in regards to the scope of treatments that they cover. These changes include Mental Health / Behavioral Health parity, less restrictions on pre-existing conditions, and the coverage of supplemental services such as physical therapy, massage therapy, acupuncture, and other holistic health services. The majority of the insurance panels will allow you to apply for medical credentialing right after you received your license. But there are a few that want a year, two years, or even three years.

There are different regulations for each state. Some will require two years, and BCBS in GA, for example, only requires two years. But there are ways to get credentialed sooner. Usually you can get credentialed if you are past one year of holding your license. Since a lot of the credentialing process is regulated by the state, even with national insurance companies, the state has much to do with the process to apply. What does the Affordable Health Care Act hold in story for credentialing? 2013 is going to be a transition period. It is going to be a time for insurance companies to start putting into place the changes for 2014. There should be more availability within the insurance panels. Because more people will have insurance, there will be a need to have more providers credentialed. The more members you have, the more providers you are going to need.[2] There may be a few different challenges as the year progresses and more insurance companies are formed. 2014 is the year that all of the changes will take place. For those living in urban areas where the panels are shut down for now, 2014 should open up the major panels, but it also may open up some new insurance companies.

Personnel Credentialing Personnel credentialing is typically undertaken at commencement of employment (initial application) and at regular intervals thereafter (reappointment). Credentialing of vendors or other organizations may begin prior to the purchasing process and be repeated regularly. Political Credentialing Political parties credential delegates at their conventions. Paperless Credentialing Paperless credentialing is the process of doing credentialing through a software package. With the internet, many web-based programs have been created to help automate the process of paperless credentialing Reference: Wikipedia, (2013). Credentialing. Retrieved 2/13/13 from http://en.wikipedia.org/wiki/Credentialing