Reference no: EM133308524

Need assistance with my assignment on a sentinel event - the event is that a mother passed away during a C-section due to low platelets, this was documented in her chart throughout her entire pregnancy and staff failed to recognize the signs and the mother did during childbirth.

I need help identifying who this is reported to, identifying the point in time when the error should have been detected before it occurred, what part of the process/procedure was missed that contributed to the sentinel event?, what agencies would be involved that is accredited agency (OSHA, ACHA, CMS, CDC, CLIA, TJC, AHCA), what is the agencies purpose, what is the reporting expectations based on the incident?

In addition to that I need assistance creating a fishbone diagram, need assistance with created a root cause analysis report. I need to identify the data needed to to be collected to determine the cause, rational for the data chosen, what human factors were relevant to the outcome, what process errors were relevant to the outcome, were there any steps in the process that did not occur as intended, did the equipment performance affect the outcome, where else could this have occurred, did the staff performance meet expectations during the event?

Need assistance in developing an action plan. what are risk reduction strategies, improvement of process or systems, communication barriers, training, equipment, policies and procedures.

What monitoring process will be used to evaluate the success of the corrective action plan? What is the legal action, public relations, equipment/supplies, education/training, patient centered communication methods, and staffing?