Choose 2 Sentinel Events Cited In Box 235 On Page 424

Choose 2 Sentinel Events Cited In Box 235 On Page 424 Of Your Textboo

Choose 2 sentinel events cited in Box 23.5 on page 424 of your textbook, as an example to consider. What would you suggest to prevent a reoccurrence? Decide under what circumstances you would inform the patient and family and under what circumstances you would withhold the information. Mini Presentation Grading Rubric - Score = 10 pts

1. Used professional tone and language, --- 2pts

2. Answered/anticipated questions, effective communication - 2pts

3. Emphasis on safety, risk reduction links to patient/person-centered care - 2 pts

4. Solid knowledge base of topic is evident - 2pts

5. Organized/cohesive - 2pts

Paper For Above instruction

Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, and they signal the need for immediate investigation and response to improve patient safety. In this discussion, I have selected two sentinel events cited in Box 23.5 on page 424 of the textbook, analyzing their causes, preventive strategies, and communication considerations with patients and families.

First Sentinel Event: Medication Error Leading to Patient Harm

A common sentinel event highlighted is a medication error resulting in serious patient injury or death. These errors often stem from factors such as misreading prescriptions, administering incorrect doses, or providing medications to the wrong patient. To prevent such reoccurrences, instituting robust medication safety protocols is essential. This includes implementing barcode medication administration (BCMA), double-check systems by nurses and pharmacists, and computerized physician order entry (CPOE) systems that reduce manual entry errors. Regular staff training and competency assessments further promote adherence to safety protocols.

In terms of communication, transparency is crucial. When a medication error has occurred, informing the patient and their family promptly is an ethical obligation and part of transparent communication practices. Patients deserve to be informed about what happened, the potential consequences, and the steps being taken to mitigate harm. However, the extent of disclosure should be guided by the severity of the error and the patient's preferences, maintaining honesty while displaying empathy. In less severe errors with minimal patient impact, withholding detailed information might be appropriate if disclosure could cause undue anxiety, but this must be balanced against the duty to be truthful.

Second Sentinel Event: Surgical Error (Wrong Site or Wrong Procedure)

Surgical errors, such as performing the wrong procedure or operating on the wrong site, are catastrophic sentinel events. These errors can be prevented through preoperative verification processes, standardized checklists like the WHO Surgical Safety Checklist, and radiological confirmation before incision. Ensuring clear communication among all team members and involving the patient in confirming their surgical site beforehand also enhances safety.

Regarding communication, transparency with the patient and family is vital, especially when the error has caused harm. Honest disclosure fosters trust, allows the patient to understand the situation, and participate in shared decision-making regarding corrective actions. If the error is identified immediately during surgery and no harm has occurred, disclosure should still be considered, recognizing ethical obligations and the importance of honesty. Conversely, if the error is minor, self-corrected promptly without impact, withholding detailed disclosure might be justified temporarily, but full disclosure should occur afterward, aligned with patient rights and institutional policies.

Preventive Strategies and Ethical Considerations in Communication

Preventing sentinel events requires a multidisciplinary approach involving staff education, standardized protocols, adherence to safety checklists, and fostering a culture of safety where staff feel empowered to speak up about concerns. Technologies such as electronic health records (EHRs) and clinical decision support tools are instrumental in reducing errors.

Communication with patients and families about adverse events should be guided by ethical principles of transparency, honesty, and compassion. Immediate disclosure is generally recommended when patient safety is compromised, as it is integral to trust-building and legal considerations. In cases where disclosure could cause significant distress and if the event is minor, withholding information temporarily might be acceptable with a plan for full disclosure later, aligning with policies like the Agency for Healthcare Research and Quality (AHRQ) guidelines on disclosure of adverse events.

Conclusion

In conclusion, addressing sentinel events such as medication errors and surgical mistakes requires systematic preventive measures and transparent, empathetic communication strategies. Emphasizing safety and patient-centered care involves fostering a culture of openness, continuous quality improvement, and ethical responsibility. Ensuring that patients and families are appropriately informed builds trust and supports shared decision-making, ultimately enhancing the quality and safety of healthcare delivery.

References

• Leape, L. L., & Berwick, D. M. (2005). Five years after To Err Is Human: what have we learned? The Journal of the American Medical Association, 293(19), 2384-2390.
• makary, M. A., & Daniel, M. (2016). Medical error—the third leading cause of death in the US. BMJ, 353, i2139.
• The Joint Commission. (2020). Sentinel Event Policy and Procedures. Retrieved from https://www.jointcommission.org
• Gawande, A. (2010). The Checklist Manifesto: How to Get Things Right. Metropolitan Books.
• McDonald, K. M., et al. (2010). Care coordination and patient safety. Medical Care Research and Review, 67(4), 448-473.
• Walter, J. K., et al. (2014). Ethical considerations in reporting medical errors to patients. Journal of Medical Ethics, 40(10), 679-684.
• Weingart, S. N., et al. (2005). Computerized physician order entry and medication safety. Journal of Patient Safety, 1(1), 6-14.
• U.S. Department of Health and Human Services. (2018). Strategies for Improving Safety and Quality in Healthcare. AHRQ Publication.
• Wachter, R. M. (2012). Patient safety at ten: Unmistakable progress and lingering challenges. Health Affairs, 31(9), 2049-2056.
• Glassman, P. A., & Donovan, L. (2014). Transparency and disclosure in healthcare: Ethical imperatives for patient safety. Bioethics, 28(9), 509-515.