Sentinel Event Mooding: A Case Study

QI teams should investigate errors relating to safety of care, especially when harm occurs. In review, Pam had already determined that the elevated temperature should have been discovered during Renee’s previous shift. That may be the case, but it is not the central issue. The cause of the infection is not mentioned. While it may be true, Renee missed surveillance, which is used for early detection, the bigger issue is the root cause of Felix’s infection. Renee missed one temperature, and there are many other ways of discovering a postoperative

Nightingale Community Hospital identified a recent sentinel event involving the ambulatory surgical center. A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof (http://www.jointcommission.org/sentinel_event). A three year old female presented to the hospital on September 14th for a planned outpatient procedure. The child was accompanied by her mother. The mother registered the patient with the registrar prior to the procedure. The patient and her mother went to the pre-operative area to complete the informed consent and the necessary physical assessment. The pre-operative nurse obtained the necessary contact

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

Every one of us has relied on a medical professional at least a few times in our lives. When we get seriously ill, or suffer a serious injury, we put our health in the hands of doctors, nurses, and pharmacists, fully expecting to be treated with a certain degree of professionalism and safety. Unfortunately, sometimes the expected care is not given, or not given to the extent which the ailment requires. In these situations, we can feel blindsided, confused, even taken advantage of.

This critical incident took place during my first six-week placement on the ward (Eleanor east). My rationale for this critical incident is because of the impact it had on me. I did not know that the side effects of hip replacement surgery could result in DVT (deep vein thrombosis), which could be very critical physically and mentally.

As noted, on February 29, 2016, the patient was nonetheless admitted to the UCR hospitalist. This was a senior member of the UCR hospitalist team who knew or should have known all of the policies and procedures for admission, and should never have admitted the patient as an attending to the hospital. In so doing, he was directly and deliberately interfering with the doctor patient relationship.

The process is an action plan that tends to illuminate on the strategies to be employed with the purpose of reducing the risk of a similar sentinel event such as that of Mr. B’s scenario. It addresses the responsibility for the oversight, implementation, pilot testing, as well as timelines and strategies for the measurement of actions that are effective (Lewis et al, 2014). All the root cause analysis (RCA) findings conducted above should help in the determination of the appropriate action plan. The appropriate improvement plan in this scenario should encompass the reevaluation of the events that led up to the code blue of Mr. B. The plan should look at the staffing mix, if the licensed personnel are trained appropriately, the patient to nurse ratio in the ER and the types of patients that were in the ER at the time. When

Several errors and hazards can be identified as possible factors leading to the sentinel event. The ER appeared to be terribly understaffed that day with only one ER physician, one RN, one LPN, and a secretary.

3) Surgeon: Was directly involved in the events leading up to the sentinel event. The surgeon was responsible for all activities taking place in the surgical suite and directly related to the surgery of the pediatric patient. The surgery was completed safely and successfully; however, the surgeon had relevant information in the patient chart at his office yet did not share this information with the hospital. He also did not supply an appropriate or accurate H&P that would have included custodial status for the pediatric patient to the hospital. The surgeon is greatly concerned in the events that lead to the sentinel event and wants to ensure that his patients will be cared for and safe at Nightingale Community Hospital.

University Hospital is a well known hospital with a level 1 trauma treatment center for the tri-county area of a northwestern state, the hospital enjoys the fact they are known for their promising reputation among healthcare professionals and the public they serve. Jan Adams is an OR supervisor that has been working there for ten years, as a professional she makes surgeons follow protocol as required and enjoys working with trauma patients. One Friday night, which is the busiest day of the week for the trauma department; the unit was notified that a helicopter was on its way with a 42 year old man who had been in a car accident. Shortly after the patient arrived to the trauma center, the resident and other medical staff noted that he was in very bad physical conditions, needed immediate surgery or otherwise he was going to die. The issue was that the on call surgeon had to be present during the surgery and had not yet arrived, but regardless of the matter and protocol they proceeded with medically treating the patient immediately. The concern is that in doing so they violated medical procedures and put the patients safety at risk, this lead to a long list of ethical issues for example, patient well-being, impaired healthcare professional, adherence to professional codes of ethical conduct, adherence to the organization’s mission statement, ethical standards, and values statements, management’s role and responsibility, failure

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency

November, 1999 brought about a release of a report prepared by the prestigious National Academy of Science’s Institute of Medicine (IOM) making medical mistakes and their magnitude of the risks to patients receiving hospital care to common public knowledge. The IOM concluded that between 44,000-98,000 deaths occur annually because of medical errors. Among a general agreement was that system deficiencies were the most important factor in the problem and not incompetent or negligent physicians and other caregivers (Sultz & Young, 2010). An excellent example of a system deficiency that leads to a crisis and sentinel event was the highly publicized overdose of Heparin to Dennis Quaid’s newborn twins in 2007.

There are errors and hazards in care that occurred in the Mr. B scenario. One error was the emergency room physician’s failure to recognize the signs and symptoms of deep vein thrombosis (DVT) that Mr. B was presenting. If not treated early, a DVT can become a pulmonary embolism, a fatal condition that Mr. B unfortunately developed. Another error in care that happened in the Mr. B scenario is the nurses’ failure to monitor Mr. B’s ECG and respirations. Early detection of critical ECG and respiratory changes could have initiated medical interventions that would have saved Mr. B’s life. One hazard is the emergency room nurses’ heavy patient load at the time of Mr. B’s sentinel event. Another hazard is having a licensed

There were multiply factors that contributed to the above scenario; Larkin and Burton writes that “after this near-miss, failure to rescue incident” (p. 394) a task force consisting of management, clinical nurse specialist (CNS) and unit educator convened to discuss the event. The task force concluded that the nursing staff members were ineffectual in critically evaluating the patient’s signs and symptoms. The CNS chose a framework that utilized “Bloom’s Taxonomy of Educational Objectives”, that provided measurable outcomes to the educational activity and enabled the nursing team to optimize their critical skill levels. A workshop to assist staff to navigate through the case study in a realistic manner was implemented (Larkin & Burton, 2008, p.395).

Since the nurses did not know their patients after report, there was a delay in proper treatment. The nursing staff therefore did not have sufficient information in order to improve the quality of care. From this incident, the staff then collectively ran through the charts, identifying other precautions for other patients, while trying to minimalize missing any details. The nursing staff was able to realize the unwanted outcome that came from the patient having a seizure and reevaluated the plan of care for this patient.