Question

Review an article related to a sentinel perioperative event.

Be sure to summarize the article. Include the following:

What is a sentinel event?

Give background information on the patient (i.e. age, past medical history, admitting diagnosis).

Discuss the cause of the sentinel event, if it resulted in any complications (i.e. injury, trauma, death).

Discuss preventable measures related to this event (i.e. raise side rails, review of 5 rights of medication administration, etc.).

What did you learn from the article

Answer 1

Sentinel event is characterized by an unanticipated event in hospital and any health care setting which result in serious physiological or psychological injury or death.

Example - Sever side effect of wrong medication, Surgery in the wrong part of the body, Any physical injury during treatment in hospital, rape in hospital, child abduction, etc.

Mrs. Nancy was a 45 years old female patient was admitted to the hospital for head injury 4 days back. Her serum potassium level was very high so, Mrs. Nancy's physician advised injection calcium gluconate/chloride 1 amp iv stat. The Nurse practitioner administered potassium chloride wrongly.

The patient suffers a sudden cardiac arrest which resulted in death. This is an example of the sentinel event and it is reported to a higher authority.

If the nurse practitioner followed the rights of medication administration I.e Right patient (Mrs. Nancy), Right drug (Calcium Gluconate), Right dose (calcium gluconate/chloride 1 amp), Right route (Iv), and Right time (Stat) then the situation would be different from now.

Give quality care to patients, Improve safety in health care settings, follow the patient's rights always remember the 5 rights of drug administration.