Question

Homework # 1-Sentinel Perioperative Event

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Review an article related to a sentinel perioperative event.

Be sure to summarize the article. Include the following:

1) What is a sentinel event?

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

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

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

5) What did you learn from the article?

Answer 1

1. Sentinel event is defined as any unanticipated healthcare event that occurs in hospital which results in death or any physical injury or a loss of part or loss of function .

2.The patient Mrs XYZ is diagnosed to have fibroid uterus .She has been planned to undergone Total abdominal Hysterectomy with Bilateral Salpingo-Oopherectomy. She is admitted in female ward under Dr.X with the complaints of heavy menstrual bleeding lasting for more than one week ,severe pelvic pain and frequent urination .She is almost 52 years of age.Her menstrual cycle stopped in the age of 46 years .

3.The nurse who shifted the patient to Operating room did not verify the name of the patients .There were two patients on the Pre- Operative room with a similar name .Mrs XYZ is posted for Total Abdominal Hysterectomy with Bilateral Salpingo -Oopherectomy .The other patient Mrs .ABC is posted for Cataract Surgery .The preoperative nurse sent Mrs.ABC for Performing TAH instead of Cataract correction .In Operation  room the scrub nurse while performing the WHO safety check list found this patient to  be wrong and immediately topped the surgery .

4.To prevent the sentinel events the following  measures has to be taken

• Following surgical safety check list prescribed by WHO .
• Proper patient Identification .
• Wrist band to be properly done for the patients .
• Consent to be taken .

5.It was learned by me that sentinel events must be prevented if all the protocols are being followed strictly and patient identification to be done promptly and safety checklist to be followed properly .

Answer 2

1. Sentinel event is defined as any unanticipated healthcare event that occurs in hospital which results in death or any physical injury or a loss of part or loss of function .

2.The patient Mrs XYZ is diagnosed to have fibroid uterus .She has been planned to undergone Total abdominal Hysterectomy with Bilateral Salpingo-Oopherectomy. She is admitted in female ward under Dr.X with the complaints of heavy menstrual bleeding lasting for more than one week ,severe pelvic pain and frequent urination .She is almost 52 years of age.Her menstrual cycle stopped in the age of 46 years .

3.The nurse who shifted the patient to Operating room did not verify the name of the patients .There were two patients on the Pre- Operative room with a similar name .Mrs XYZ is posted for Total Abdominal Hysterectomy with Bilateral Salpingo -Oopherectomy .The other patient Mrs .ABC is posted for Cataract Surgery .The preoperative nurse sent Mrs.ABC for Performing TAH instead of Cataract correction .In Operation  room the scrub nurse while performing the WHO safety check list found this patient to  be wrong and immediately topped the surgery .

4.To prevent the sentinel events the following  measures has to be taken

• Following surgical safety check list prescribed by WHO .
• Proper patient Identification .
• Wrist band to be properly done for the patients .
• Consent to be taken .

5.It was learned by me that sentinel events must be prevented if all the protocols are being followed strictly and patient identification to be done promptly and safety checklist to be followed properly .