tailieunhanh - 2009 Utah Sentinel Events Data Report: Identifying Opportunities for Improvement

The rest of the paper is structured as follows. The next section discusses related work and expands on Sextant’s contributions. In sections 3 through 6, we discuss the basic operation of Sextant, including its area representation, its extraction of constraints from wireless radios and sensors, and its distributed solution techniques for node and event localization. Section 7 describes how the inter- action between node and event localization can be used to refine position estimates. Section 8 describes the network protocol used to obtain and combine position estimates. Section 9 outlines the structure and complexity of the Sextant implementation. Section 10 provides results from our simulations and physical experiments and Section 11. | 2009 Utah Sentinel Events Data Report Identifying Opportunities for Improvement A joint report from UTAH DEPARTMENT OF HEALTH Utah Hoshtal Health Systems ASSO c I A T I O N March 2010 About this report The purpose of this report is to provide information on the sentinel event data collected from January-December 2009 by the Utah Department of Health. Facilities participating in the data collection include all Utah hospitals and ambulatory surgical centers. Included in this report is a historical overview of the collection process details of the data collection and the collaborative efforts underway to address issues identified in the data. Overview of sentinel event reporting in Utah In 2001 the Utah Department of Health UDOH in response to the publication To Err is Human initiated a patient safety program in partnership with the Utah Hospitals Health Systems Association UHA Utah Medical Association UMA and HealthInsight the Quality Improvement Organization for Utah. Quality and risk managers representing the healthcare sector collaborated as a learning group to better identify actual and potential events and to develop system-wide sustainable safeguards to prevent these events in the future. The reporting system was deliberately designed to shift away from a traditional focus of blame and instead encourage a just culture for collaborative system improvement. Sentinel events by their nature are rare events. Although sentinel events are not always medical errors they are indicators of system breakdown. Sentinel events can be devastating experiences to patients their families and their healthcare providers. Identification of these events across hospitals and ambulatory surgical centers provides opportunity for system-wide learning and the development of industry-based improvement strategies. Between October 2001 and April 2007 sentinel events defined as unanticipated deaths wrong site surgeries abductions and loss of function that occur at a facility hospital or .