It is the investigational process of determining underlying issues or root causes that contribute to incidents with a significant undesirable or adverse outcome – a way of doing a thorough study that involves:
The purpose of the RCA is to review our systems and processes in order to prevent a similar incident from re– occurring after we have determined the root cause of the incident
Notification of sentinel events is outlined in the Risk Management Program. A suspected sentinel event is brought to the immediate attention of the QI Coordinator and to the Chief of the Department, who decide if a sentinel event has occurred. If it is determined that the event is a sentinel event, a specialized team is assigned to perform a Root Cause Analysis (RCA) and report findings to Medical Management and the Quality Improvement Counsel Committee which implements the recommendations of the RCA to prevent reoccurrence.
QPS processes provide the framework for the organization and its leaders to achieve a commitment to provide quality patient care in a safe, well-managed environment and reduce risk to patients, staff and visitors.
Do you know what model preferred to be used for Quality Improvement?
Answer: PDCA improvement model. This requires the chosen process to go through the Plan-Do- Check-Act cycle in order to bring about an improvement.
How are clinicians involved in Quality Improvement?
Hospital Quality Improvement and Patient Safety
How has your department improved care or services?
Yes, single atoms do cast shadows! This has been understood for about 100 years but was only demonstrated experimentally recently, in this paper from 2012.
On the scale of things smaller than the wavelength of light, the shadow in the far field will never be smaller than the diffraction limit. Instead of a sharp outline that you see with macroscopic objects, the diffraction pattern formed by the shadow is a smooth function determined by the optics of the microscope.
Everything is partially transparent at this small scale as well, so the intensity of the shadow is determined by how much light the object can absorb. For individual atoms, the absorption is only significant at very narrow peaks in wavelength. So you need to be sure to tune your light source right at one of these peaks to get a decent shadow.
In the paper above, the authors trapped a single, laser-cooled ytterbium ion and used a light source tuned to a peak around 369.5 nm. That means they were imaging in UV, but in principle this approach could work with visible light as well. The final image showed about a 3% decrease in intensity at the center of the shadow. The wavelength of light used to illuminate the atom had to be precise to about one part per billion or the shadow disappeared.
The abdominal cavity is the internal area of the body between the chest and hips that contains the lower part of the esophagus, stomach, small intestine, and large intestine. The esophagus carries food and liquids from the mouth to the stomach, which slowly pumps them into the small and large intestines. Abdominal adhesions can kink, twist, or pull the small and large intestines out of place, causing an intestinal obstruction. Intestinal obstruction, also called a bowel obstruction, results in the partial or complete blockage of movement of food or stool through the intestines.
What causes abdominal adhesions? Abdominal surgery is the most frequent cause of abdominal adhesions. Surgery-related causes include cuts involving internal organs handling of internal organs drying out of internal organs and tissues contact of internal tissues with foreign materials, such as gauze, surgical gloves, and stitches blood or blood clots that were not rinsed away during surgery Abdominal adhesions can also result from inflammation not related to surgery, including appendix rupture radiation t
Source: Abdominal Adhesions | NIDDK
Nonsteroidal Anti-Inflammatory Agents may enhance the adverse/toxic effect of NSAID (COX-2 Inhibitor).
The prescribing information for both celecoxib and etoricoxib recommends avoiding concurrent use with any other NSAID due to an increased risk for adverse reactions,
So.. Concurrent use of another NSAID together with a COX-2 inhibitor is not recommended and should be avoided.