Discuss a sentinel event that occurred in your facility or unit and what was the outcome?
Did any policy/procedure, guideline, change developed in response to the event? Were you involved with the event in any way?
Sentinel events are such infrequent events that occur in health services due to deficiencies in system and processes. Such events can hamper the care delivery procedures as well as the organizational image. In some cases, these events can be fatal. One of such event is medication error. Medication error is very common sentinel event (Wu & Steckelberg, 2012). In spite of the working under huge regulation, during the change in shifts, one nurse in our healthcare organization made a wrong documentation about a patient’s blood pressure measure. The nurse did not put the last measured blood pressure on a cardiovascular patient’s report and hand over the documents to the nurse in next shift. Based on the previous BP, doctor did not prescribe medication for high blood pressure. The patient experienced massive stroke due to uncontrolled blood pressure.
The hospital authority based on the patient family’s claim sued the nurse. In response to the described event, the use of electronic health record system was started in the healthcare settings. Through this system, nurses started to put all the medications and other documents of a patient in electronic software (Wu & Steckelberg, 2012). As a result, the confusion within nurses regarding manual documentation during the shift change has been resolved. This procedure helped the nurses to avoid medication error and improved the quality of care delivery. As a nurse, I have also used the electronic health record system for documenting all the patient’s data.
Joint Commission established the ‘2016 National Patient Safety Goals’ (NPSG) for reducing these kinds of sentinel events. The sentinel event in our organization was related to the NPSG.03.06.01 goals related to patient’s medicine safety (Data, 2012). The purpose of setting this goal is to make it sure, that nurses are rechecking the correct medication and any kind of change in patient’s status or medication before administrating patient’s medication.
Data, S. E. (2012). Root Causes by Event Type 2004–2012. Washington, DC: The Joint Commission.
Wu, A. W., & Steckelberg, R. C. (2012). Medical error, incident investigation and the second victim: doing better but feeling worse?. BMJ quality & safety, 21(4), 267-270.