A Reflection on Sentinel Events in Healthcare The Joint Commission (TJC) defines a sentinel event as an unforeseen incident that results in critical injury or death of a patient (Cherry & Jacob, 2017). After a sentinel event has occurred, TJC mandates the healthcare facility perform a root cause analysis (RCA) so they fully understand the why the event happened and can implement an action plan to prevent them from recurring (Cherry & Jacob, 2017). TJC will review the RCA and subsequent interventions taken by the facility to determine if they complied with national quality standards. In this reflection I will review some of most common root causes of sentinel events, pinpoint the root cause that I believe poses the greatest risk to patient …show more content…
The most commonly identified causes of these sentinel events include human factors, flawed leadership, and poor communication (“Sentinel event statistics released for 2014,” 2015). The concept of human factors can be applied to the individual, the healthcare team, and how a person performs and works within their environment (Doerhoff & Garrison, 2015). Individual human factors that have a negative impact on the delivery of patient care include cognition, fatigue, and physical ability (Doerhoff & Garrison, 2015). TJC has found that failed leadership within the healthcare setting fails to create a safe culture that allows sentinel events to occur (Ulrich, 2017). Hospital leaders can construct a culture of safety by focusing on accountability, recognizing unsafe conditions, trust, strengthening systems, and continually evaluating and assessing how they can improve patient and employee safety (Ulrich, 2017). Poorly communicating dietary restrictions, administration, and patient information amongst members of the healthcare team has significantly contributed to medical errors (Ulrich, 2017). From 1995 to 2015, TJC recognized ineffective communication as the leading root cause of sentinel events (Burgener, …show more content…
Previously, ineffective communication, was recognized as the foremost cause of sentinel events (Doerhoff & Garrison, 2015). Interestingly, the individual human factor, fatigue, leads to ineffective communication (Doerhoff & Garrison, 2015). Fatigue causes delays in attention and memory, confusion, and irritability (Gardner & Dubeck, 2016). All of which negatively affect a nurses ability to communicate with patients, providers, and other nurses. Furthermore, if hospital leaders allow nurses to work excessive hours without a break or increase a nurse’s workload, it can worsen fatigue leading to poor decision making. Poor leadership can lead to the development of fatigue which then results in ineffective communication. The interconnection of human factors, especially fatigue, with the other top root causes of sentinel events, indicates that human factors are indeed the root cause that poses the greatest potential danger to patient
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
In 2011 The Joint Commission called attention to healthcare worker fatigue and the impact it was having on patient safety. They found a direct link between healthcare worker fatigue and adverse events. They recommended healthcare facilities assessed their policies to identify fatigue-related risks, such as off-shift hours and consecutive shift work, and review their staffing to address areas that may be contributing to nurse fatigue (Martin, 2015).
Alarm fatigue is a growing problem that causes nurses to feel overwhelmed and not perform to the best of their abilities. Many people don’t understand the concept of alarm fatigue until they are in a hospital and hear the different noises going on first hand. Alarm fatigue occurs when nurses or other health care members have sensory overload due to the alarms, which then lead to ignoring the alarms raising concerns with patient safety (Horkan, 2014).
This systems limits patient involvement creates a delay in patient and nurse visualization. Prior to implementation of bedside shift reporting an evidenced based practice educational sessions will be provided and mandatory for nursing staff to attend (Trossman, 2009, p. 7). Utilizing unit managers and facility educators education stations will be set up in each participating unit. A standardized script for each nurse to utilize during the bedside shift report will be implemented to aid in prioritization, organization and timeliness of report decreasing the amount of information the nurse needs to scribe and allowing the nurse more time to visualize the patient, environment and equipment (Evans 2012, p. 283-284). Verbal and written bedside shift reporting is crucial for patient safety. “Ineffective communication is the most frequently cited cause for sentinel events in the United States and in Australian hospitals 50% of adverse events occur as a result of communication failures between health care professionals.” Utilizing written report information creates accountability and minimizes the loss in important information during the bedside shift report process (Street, 2011 p. 133). To minimize the barriers associated with the change of shift reporting process unit managers need to create a positive environment and reinforce the benefits for the procedural change (Tobiano, et al.,
The concept of risk management is relatively new, as hospitals look to prevent hospital-acquired infections (HAIs), falls, injuries, and other forms of preventable harm, rather than reacting once harm has already taken place. Before this concept became a best practice, most health organizations relied on malpractice and liability insurance to protect against losses and mitigate the effects of accidents and poor patient outcomes (Colorado State University-Global Campus, 2014). Today, risk management is an integral facet of a healthcare facility’s business practice in preventing risks, ensuring regulatory compliance, minimizing financial damage, and preserving its reputation in the community. Although most large
In the recent past, nursing has come to the forefront as a popular career amongst students across the globe. The demand for nurses has kept increasing gradually over the years. In fact, the number of registered nurses does not meet the demand of the private and public health sector. This phenomenon has resulted in a situation where the available registered nurses have to work extra hours in order to meet the patients’ needs. With this in mind, the issue of nurse fatigue has come up as a common problem in nursing. According to the Canadian Nurses Association (CNA), nurse fatigue is “a feeling of tiredness” that penetrates a persons physical, mental and emotional realms limiting their ability to function normally. Fatigue does not just involve sleepiness as has been assumed before. It involves utter exhaustion that is not easily mitigated through rest. When nurses ignore the signs of fatigue, they risk the development of chronic fatigue and other health problems that may not be easily treated. Additionally, fatigue may cause nurses to lose more time at work as they may have to be away from work for several days to treat it. The issue of nurse fatigue has permeated the nursing profession to the extent of causing errors in the work performed by nurses. Fatigue causes a decrease in a nurse’s ability to make accurate decisions for themselves and their patients. It is therefore important to find ways to curb nurse fatigue such that it is no longer a problem. Nurse fatigue is a danger to the patients, organizations and to the nurses themselves and must be mitigated adequately.
After review of the timeline of the events surrounding Mr. B, there are several causative factors that led to this sentinel event. These are inappropriate staffing, inability to identify trends of deterioration, policy for conscious sedation was not followed, inadequate observation and monitoring, failure to respond to alarms, inadequate home medication evaluation, medication dosing, appropriate medication administration times, and failure to start cardiopulmonary resuscitation in a timely manner.
Human factors are derived from construction and adapted to a system of development in health care by carefully examining the relationship between people, environment, and technology. The consideration of human factors acknowledges the capability or inability to perform a precise task while executing multiple functions at once. Human factors provide an organized method to prevent errors and create exceptional efficiency. Careful attention must be exercised in all levels of care such as the physical, social, and external environment. It is also vital to carefully consider the type of work completed and the quality of performance. Applying human factors to the structure of healthcare can help reduce risks and improve outcomes for patients. This includes physical, behavioral, and cognitive performance which is important to a successful health care system that can prevent errors. A well-designed health care system can anticipate errors before they occur and not after the mistake has been committed. A culture of safety in nursing demands strong leadership that pays attention to variations in workloads, preventing interruptions at work, promotes communication and courtesy for everyone involved. Implementing a structure of human factors will guide research and provide a better understanding of a nurse’s complicated work environment. Nurses today are face challenges that affect patient safety such as heavy workloads, distractions, multiple tasks, and inadequate staffing. Poor communication and failure to comply with proper protocols can also adversely affect patient safety. Understanding human factors can help nurses prevent errors and improve quality of care. In order to standardize care the crew resource management program was
Each year this panel of experts put a microscope on patient safety across the board. They decide where upmost attention needs to be paid. Sometimes items leave the list because there are been strides take to improve in that area and sometimes it continues to stay on the list because they believe the relevance and importance is growing. Healthcare is evolving b...
With patient safety always being the number one priority FTR is the worst case scenario for the hospitalized patient. In an article titled “Failure to Rescue: The Nurse’s Impact” from the Medsurg Nursing Journal author Garvey explains ways FTR can occur “including organizational failure, provider lack of knowledge and failure to realize clinical injury, lack of supervision, and failure to get advice.” Nurses are problem solvers by nature, they heal the sick and help save lives. FTR is a tragic experience for everyone involved. The recent surge in this happening across the country has given FTR cases widespread media coverage. Hospitals are trying to figure out what the root cause is and how they can be prevented. Fortunately, with the advancement of technology and extensive research many hospitals have developed action plans and procedures to help prevent the early warning signs from being
The nursing profession has changed significantly over the years. In our fast-paced world of health care and technologically-advanced society, nurses are experiencing higher workloads than ever before. According to a survey done by the Agency for Healthcare Research and Quality’s ([AHRQ], 2012), more than 50% of nurses work in a crisis mode trying to do too much too quickly, and safety is sacrificed to get more work done.
In 2003, TJC formed the leading set of National Patient Safety Goals (NPSGs) program; these goals were recognized to assist organizations to address specific areas of concern in respect to patient safety. A panel of experts updates these NPSGs periodically, this panel, is called the Patient Safety Advisory Group, and is composed of nurses, physicians, pharmacists, risk managers, clinical engineers, and other professionals with experience in addressing patient safety issues in healthcare
The rate of errors and situations are seen as chances for improvement. A great degree of preventable adversative events and medical faults happen. They cause injury to patients and their loved ones. Events are possibly able to occur in all types of settings. Innovations and strategies have been created to identify hazards to progress patient and staff safety. Nurses are dominant to providing an atmosphere and values of safety. As an outcome, nurses are becoming safety leaders in the healthcare environment(Utrich&Kear,
Several consequences of high nursing workload have been proven to hinder the quality of patient care. Carayon and Gurses’s research (2008) indicates that heavy workload can contribute to errors, shortcuts, guideline violations, and poor communication with physicians and other providers, thus compromising the quality and safety of patient care. In addition, the research not only implies that patients may not receive proper care, but also they can experience less satisfaction with
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 coordination task force with the help of government agencies. These government agencies are responsible for making health pol-icies regarding patient safety to which every HCO must follow (Schulman & Kim, 2000).