Author: steinbrechersite
I. Sentinel Event
In support of its mission to continuously improve the safety and quality of health care provided to the public, The Joint Commission in its accreditation process reviews hospitals’ activities in response to sentinel events. The accreditation process includes all full accreditation surveys and, as appropriate, for-cause surveys, and random validation surveys specific to Evidence of Standards Compliance (ESC).
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Such events are called “sentinel” because they signal the need for immediate investigation and response.
The terms “sentinel event” and “error” are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events.
II. Goals of the Sentinel Event Policy
The policy has four goals:
1. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events
2. To focus the attention of a hospital that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or organizational culture),and on changing the hospital’s culture, systems, and processes to reduce the probability of such an event in the future
3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention
4. To maintain the confidence of the public and accredited hospitals in the accreditation process.
FACT: ON OCTOBER 31, 2015 JAKE SEPPEL STEINBRECHER , 7 YEARS OLD AT THE TIME,WAS OVERDOSED BY GOOD DAY PHARMACY AT GOOD DAY PHARMACY 2033 N Boise Ave, Loveland, CO 80538. “SOMEONE” AT THIS GOOD DAY PHARMACY MADE THE LIQUID SUSPENSION OF CLONIDINE AT 1000 TIMES THE CONCENTRATION. JAKE STEINBRECHER HAD SENSORY PROCESSING DISORDER, THAT HE WAS SOON TO GROW OUT OF THIS CONDITION WITH SUPPORT AND OCCUPATIONAL THERAPY. IN FACT, HE DID ACTUALLY OUT GROW IT. HE WAS NEVER PUT ON THE CLONIDINE AGAIN, AND HAD THE BEST SEMESTER OF HIS LIFE, DRUG FREE!!
FACT: THE OVERDOSE CAUSED HALLUCINATIONS, TREMENDOUS PAIN, SEIZURES, AND BRAIN SWELLING FOR 3 DAYS IN JAKE STEINBRECHER.
FACT: NARCAN IS USED AS A REVERSAL FOR CLONIDINE.
FACT: MOTHER OF CHILD ASKED, FOR THE REVERSAL NARCAN, FROM MANY DOCTORS AND WAS DENIED.
FACT: PRIOR TO THIS DAY JAKE STEINBRECHER WAS A HEALTHY BOY HIS ENTIRE LIFE!
FACT: THIS SITE CHRONICLES THE EVENTS ON AND AFTER OCTOBER 31, 2015.
FACT: GOOD DAY PHARMACY DID NOT HAVE A 24 HOUR EMERGENCY NUMBER TO CALL.
FACT: JOSEPH POLING PHARMACIST SAID, “WE DID NOT SHAKE THE BOTTLE ENOUGH, AND INSTRUCTED US TO LET JAKE SLEEP FOR A COUPLE OF HOURS AND LET THE CLONIDINE WEAR OFF.”
FACT: VICKI EINHELLIG GOOD DAY PHARMACY OWNER IS ON THE COLORADO STATE PHARMACY BOARD.
FACT: CHILDREN’S HOSPITAL COLORADO RELEASED JAKE WITH NO FOLLOW UP CARE REQUIRED.
FACT: NO ONE FILED THE OVERDOSE AS A MANDATORY REPORTER
FACT: DEATH CERTIFICATE IS A PUBLIC RECORD. IT TOOK NEARLY 5 MONTHS.
FACT: THE SATE OF COLORADO DEEMS CHILDREN WORTHLESS, THEY HAVE NO EARNING POTENTIAL. WHO WANTS THE BLOOD MONEY ANYWAY? MONEY WILL NOT MAKE A NEW JAKE SEPPEL STEINBRECHER. DEAD ON JUNE 8, 2016. AT 8 YEARS OLD.
FACT: NO ONE WILL BE HELD ACCOUNTABLE, THE STATE OF COLORADO AND THE USA PROTECTS MEDICAL PROFESSIONALS OVER THE PATIENTS.
FACT: IF A NON MEDICAL PROFESSIONAL HAD FORCED A CHILD TO INGEST A POTENTIALLY FATAL LEVEL OF A DRUG. THEY WOULD BE ARRESTED IMMEDIATELY!
FACT: JAKE HAS/HAD A VERY SMART RAT NAMED MAX. I AM LOOKING AT MAX THE RAT NOW. MAX THE RAT: KNEW JAKE WAS VERY ILL, SHAKING HIS CAGE DOOR TO BE WITH JAKE IN HIS LAP PRIOR TO RUSHING JAKE TO THE HOSPITAL JUNE 7, 2016.
FACT: HEPARIN PREVENTS CLOTTING
FACT: JAKE STEINBRECHER CRASHED AND DIED AFTER 40 MINUTES OF “CODE BLUE“AND CONTINUOUS EFFORTS TO SAVE HIM. MOTHER OF CHILD SAW IT ALL. JUNE 8, 2016. MOTHER OF CHILD WAS SCREAMING, “JAKE DON’T GO, MOMMY LOVES YOU AND NEEDS YOU!”
FACT: JAKE STEINBRECHER LOVED MATH, SCIENCE, HIS FRIENDS AND FAMILY, AND HIS MOMMY VERY MUCH…and his rat Max.
FACT: JAKE STEINBRECHER WAS A DANCER
FACT: JAKE SEPPEL STEINBRECHER WAS AFRICAN AMERICAN
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