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...

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…