A sentinel event is a serious, unexpected or life-threatening event that occurs in a health care setting. Sentinel events are typically associated with preventable harm to patients and can result in significant negative outcomes, including death.
Nurses play a vital role in the prevention of sentinel events. By understanding the root causes of these events and taking steps to mitigate risks, nurses can help ensure that patients receive the highest quality of care possible.
The following case study examines a sentinel event that occurred in a hospital setting. The patient in this case was admitted to the hospital for surgery and subsequently developed complications that led to her death.
This case highlights the importance of effective communication between all members of the health care team.
Communication is the key to a company’s success. When Tina, a kid about to be discharged, was believed to have been kidnapped from the area, Nightingale Community Hospital was unfortunately lacking in this department. All of the personnel in charge of Tina’s care at the time offered their thoughts on what occurred and what preventative actions might have been taken.
However, their statements were all different. It was only when the CCTV footage was reviewed that the truth of what happened was revealed.
Had the staff at Nightingale been better communicators, it is likely that this incident could have been avoided. In order to prevent future sentinel events, it is essential that a method of communication is established and adhered to by all members of staff. This case study will explore the role of communication in sentinel event management and how important it is to have an effective system in place.
Dr. Zendle is flabbergasted that one of his patients could get into a situation like this, and he places the blame on the nurses. He doubts their intellect, asking how they missed the fact that the girl’s parents were divorced and she has sole custody only her mother. Due to legal rights, the father is not permitted to take his daughter against her will, which creates significant legal ramifications concerning inadvertent behavior.
The staff is at a loss for words because they had no way of knowing this information. The father never came to visit his daughter in the hospital, and the mother was always with her.
The sentinel event in this case study is that the patient was discharged to the wrong person. The staff did not know that the girl’s parents were divorced and only the mother had custody. This led to big legal issues because the father was not allowed to take his daughter due to legal rights.
This case highlights the importance of communication among healthcare providers. In this instance, had the staff been aware of the girl’s family situation, they could have prevented her from being discharged to the wrong person. It is essential that nurses and other healthcare providers are aware of their patients’ personal situations in order to provide the best possible care.
Dr. Munoz is the number one ENT for outpatient surgeries at Nightingale and is afraid that with his neck on the line for this casualty, he will lose credibility. Surgeons are responsible not only for performing medical operations but also ensuring patients get from pre-operative care to surgery to post-operative care safely. In these respects, Dr. Munoz did his job well, but was still unhappy with the negligence of the nursing staff.
“I don’t understand how this could happen,” Dr. Munoz said as he paced back and forth in the break room. “I told the nurses to make sure the patient was properly hydrated and that her blood pressure was stable before surgery. I even wrote it down in the chart.”
The other surgeons in the room tried to console him, but Dr. Munoz was inconsolable. He had been at Nightingale for five years and had built up a good reputation as an expert ENT surgeon. Now, one mistake by the nursing staff could ruin everything.
The most common issue was a lack of communication, which was mentioned by almost every person involved in the sentinel incident. The best method to prevent this is to start a risk management plan as soon as the patient arrives at your door.
This plan should include regular check-ins with the patient, as well as their family or friends, to make sure they understand what is happening and feel comfortable with the care they are receiving.
It is also important to have a clear chain of command when it comes to patient care. In this case, there was confusion about who was responsible for what, which led to critical information not being passed along in a timely manner. By having a clear hierarchy, everyone will know exactly who to go to with questions or concerns.
Finally, it is essential to learn from mistakes that are made. In this instance, the hospital did not initially own up to the error and took too long to apologize. While it is never easy to admit fault, it is important to do so in order to learn from the mistake and prevent it from happening again in the future.
Because the child should demand that the registrar erase all data, including any information regarding custody of the kid and who is authorized to receive the juvenile patient. A code may then be assigned to each household, and wristbands can be produced with that code, and if someone picking up the child at discharge does not have the same bracelet, he or she will be kept in the care of the discharge nurse until a legal guardian of the kid is available.
If a sentinel event does occur, then NCH should immediately begin an investigation. All employees who were working at the time of the event should be interviewed, and any video footage should be collected and reviewed. After the initial investigation is complete, a root cause analysis should be conducted to determine what exactly went wrong and how it can be prevented in the future.NCH should also review its policies and procedures to see if anything needs to be changed or updated in light of the sentinel event.
It is important for NCH to learn from any sentinel events that occur, so that they can be prevented in the future. By taking immediate action to investigate the cause of the event and making changes to policies and procedures as needed, NCH can ensure thatsentinel events are prevented and that patient safety is always a top priority.
