Sentinel Event Report

Sentinel events are a major cause of deaths in hospitals, these deaths may have been prevented if there was not a break down in the communications process. Due to the rise of such events it has been decided that by the Commission that National Patient Goals would include patient safety as an area of focus.

There was no hand off of the cell phone number the mother provided to the pre-op nurse. As there is no documented area on any of the forms for this information, the process relies on verbal handoff and memory of the nurse. There was no alternate phone number available for the nurse to contact the mother or other designee.

In the health care business, there are certain standards and laws that have been put in place to protect our patients and their personal health information. When a health care facility fails to protect their patient’s confidential information, the US Government may get involved and facilities may be forced to pay huge sums of money in fines, and risk damaging their reputation.

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.

On 3/22/18, Linda Blaylock came to the administrators office and alleges someone (later identified as former employees, Greta O’quine, CNA and Stephone Else, Medication aide) told her that Robin Lyles, LVN, ADON instructed the nurse Phillip to “take them to china” when a resident has unwanted behaviors, which creates an adverse reaction and possibly death. Ms. Blaylock explains the phrase means to use antipsychotic drugs and Benadryl to sedate the residents. Ms. Blaylock alleges this was told to Gwen but did not do anything about it. However,

At the time of the incident, I felt very inadequate. I felt that I was not a good advocate for Ms Lisa, nor did the AMU nurse fulfil the clause of the NMC (2015)’s Code of Conduct and act in patient’s best interests (NMC (2015)). For me, the hardest part was not able to help Ms Lisa. However, I felt that I did help Ms Lisa, only in a small way but could

The Joint Commission also addresses safety issues through the publication and distribution of the Sentinel Event which identifies a severe breach in safety and addresses ways on how to improve processes and to prevent harm in the future. It also publishes the National Patient Safety Goals which address healthcare safety and ways to solve problems that focus on issues such as identifying patients correctly, improving communication among staff, and administering medications safely, just to name a few. “A majority of Joint Commission standards are directly related to safety, addressing such issues as medication use, infection control, surgery and anesthesia, transfusions, restraint and seclusion, staffing and staff competence, fire safety, medical equipment, emergency management, and security. The standards also include requirements for preventing accidental harm; responding to patient safety events; and the organization’s responsibility to tell patients about the outcomes of their care” (TJC,

It is not his job to do this, however, information pertinent to the patient should be made available to the hospital. Chief Nursing Officer (CNO)—is in charge of the entire nursing staff at hospitals and hospital institutes. CNO’s are responsible for the management of nurses in their department by providing feedback, training, support, and disciplinary actions when called for. CNO’s are also accountable for the development of programs and procedures that will help the hospital institutions run efficiently and promote growth (www.ejgh.org). The role of the CNO was that of an ineffective leader in that she was unavailable (why?) when the incident occurred, however she took responsibility and accountability.

Also enforced by OCR, the Patient Safety and Quality Improvement Act of 2005 (PSQIA) established a voluntary reporting system where data is analyzed and used to enhance the safety and quality of healthcare delivery. PSQIA provides confidentiality protections to healthcare providers who were previously concerned about the use of patient safety event reports in criminal, civil, and administrative proceedings. By limiting the use of event reports the fear report medical errors has decreased among many healthcare providers (Medical Errors and Patient Safety, 2008).

It is critical in today’s health care field to avoid harm and ensure that patient safety in health care environment, especially with the attention of medical mistakes little is known about the importance of avoidable harm to public. The mistakes that happen in the healthcare setting are rarely the fault of individual workers, but usually the result of problems within the system that they work.

Code Pink- Summons desigmated staff to assist whenever a patient or child goes missing, the speed and effectiveness of the staffs response is a key factor in limiting liability. In the event of a kidnapping or disaster the police will be notified and the grounds will be searched. All exits and elvevators will be sealed. Community Relations will handle the media, while social workers provide emotional support to all involved persons.

The system failures identified by Judy Smetzer in the case of the newborn Miguel revealed interesting views concerning patient safety. In the article,” Lessons from Colorado: Beyond Blaming Individuals”, the difficulties of healthcare system and medication use system led to a fatal error that killed a newborn. This case emphasized that medication errors were not caused by a failure of one single element, but the whole system. According to Smetzer (1998), one of the system failures, “staff inexperience and poor documentation had tremendously contributed to the sentinel event of the article” (p.49). When health care providers put their actions lower than their knowledge, practice without proper safety measures and documentation, then it affects

“The definition of a health professional is a person who works to protect and improve people’s health by the diagnosis and treatment of illness to bring about a complete recovery from mental, physical and social perspectives, either directly or indirectly (Kurban, 2010, pg. 760).” Nurses in the community today have acquired an increasing responsibility to intervene with medical decisions. In the past, there were clear differences between nurses and doctors. It was more common for a nurse to be supervised directly under the physician. They are not just performing Doctor’s orders anymore. The nurse role in patient care has been widely expanded. Allegations against someone can be one of the most stressful moments of their careers. Negligence

Tina's mother was upset to realize that she was missing and alerted the security officer. Subsequently, the hospital abduction code was activated in the hospital by the security officer. The hospital's security personnel contacted local law enforcement agencies alerting them of the presumed abduction of Tina after her surgery. The security officer realized while

Other concerns are conversations within the hospital cafeterias/lobbies about patients and their families, and employees sharing information throughout the hallways without a “need to know.” Once employees discover their colleagues looking at patient information without a “need to know basis,” and, other wrong doings according to the agency’s standards, their own sense of what is right and wrong instantly comes into question. Reporting the unethical behavior, the employee who had discovered the violations of patient rights is presented with a number of difficult choices. The legal basis for imposing liability for a breach of confidentiality is more extensive than ethical guidelines, which dictate the morally right thing to do.