Correcting a Sentinel Event

Sentinel Event Activity A sentinel event is described as an unexpected event that involves a severe physical or psychology injury or death or the risk of such incidents. In this case, the serious physical or psychological injury specifically incorporates loss of function or limb. Sentinel incidents are seemingly sporadic though they are clear-cut incidents that take place regardless of the patient's condition ("Sentinel Events," 2012). However, these events usually reflect the hospital and procedure deficiencies, which contribute to unnecessary patient outcomes.

Some of the most common sentinel events include medication error that result in death, suicide in inpatient wards, clinical process involving the wrong patient, and maternal deaths. As part of enhancing patient safety and quality of health care, nurse administrators play a crucial role in identifying these events, barriers that contribute to them, and developing measures to correct the barriers. Sentinel Event Example An 88-year-old male has been diagnosed with Chronic Obstructive Pulmonary Disease at a local health facility.

The patient lives with his adult daughter and her family (possibly causing harm to them) because of his condition. The 88-year-old male patient is currently receiving home health care services from Nightingale Home Care. As a result of smoking while using oxygen, the patient has caused a sentinel event. Barriers that Occurred in this Event As previously mentioned, one of the major ways for addressing sentinel events include identifying barriers i.e. communication and/or health care practices that take place in a sentinel event.

Nurse administrators play a key role in identifying these barriers as part of their initiatives to correct such events. The identification of these barriers have become increasingly important in the past few years since The Joint Commission has received and reviewed more than 11 sentinel events since April 1997 ("Lessons Learned," 2001). These events are increasingly associated with home health care patients who were injured or died because of a fire in the home.

In each of the incidents, the home health care patients were obtaining supplemental oxygen service and were more than 65 years old similar to the example described previously. According to The Joint Commission, there are several factors that contribute to home care related fires or sentinel events including living alone, flammable clothing, lack of smoke detectors or presence of redundant smoke detectors, and history of smoking while oxygen is running.

The health care practices that acted as barriers and eventually resulted in this sentinel event are lack of smoke detectors and probable patient history of smoking while oxygen is running. Moreover, it seems the health care providers did not inform the patient the dangers of smoking while oxygen is running in light of the likelihood of causing a fire. Generally, cigarette smoking has been identified as a major contributing factor to sentinel events.

Nurse Administrator's Role in Identifying the Barriers As previously mentioned, nurse administrators play a crucial role in identifying the barriers that cause a sentinel event such as communication problems or health care practices. The previously described sentinel event example is a scenario that a nurse administrator would play an important role in identifying the barriers i.e. communication and/or health care practices that caused the incident.

The role of nurse administrators in identifying the cause of this sentinel event is linked to their role in management of patient care practices in the health care facility. The role of nurse administrators in this process is attributed to their work in daily systematic assessment of complex dynamics with significant impacts on ability of nurses and other health care providers to practice in the various health care settings.

Since these professionals are already involved in assessing the complex dynamics related to nurse practice in several health care settings, they play an important role in identifying causes of sentinel events. Actually, the identification of barriers that caused this event is associated with nurse administrators' daily practice of assessing nursing practice in different health care settings including the home care setting or environment. Nurse Administrator's Role in Correcting the Barriers Apart from constantly assessing nursing practice, nurse administrator also plays an important role in correcting barriers i.e.

communication and/or health care practices that resulted in the sentinel event. The role of a nurse administrator in correcting the barriers originates from his/her responsibility in developing policies and processes that govern safe nursing practice and ensuring nurses correctly interpret and implement these policies and procedures. Actually, together with nurse managers, nurse administrators enhance patient safety through creating an environment where nurses control their own nursing practice (Ballard, 2003).

In light of these responsibilities, the nurse administrator's role in correcting the barriers entails developing policies and procedures that would govern nursing practice in every health care facility including home health care setting. Moreover, the nurse administrator should help ensure that nurses effectively interpret and implement the policies and practices in order to prevent such an event from occurring in home health care setting. However, the nurse administrator should also.