Sentinel Events in Home Health Care: Nurse Administrator's Role
This paper examines sentinel events in health care, with a focus on home health care settings. Using a case example of an 88-year-old COPD patient who caused a fire by smoking while using supplemental oxygen, the paper identifies communication failures and health care practice deficiencies as key barriers that contributed to the event. Drawing on Joint Commission data and nursing leadership literature, the paper discusses how nurse administrators use their daily assessment responsibilities to identify these barriers and then correct them by developing policies, guiding nursing practice, and fostering environments that support patient safety and nurse autonomy.
- Introduction to Sentinel Events: Definition and significance of sentinel events in healthcare
- Sentinel Event Example: Home Oxygen Fire: COPD patient causes fire smoking near oxygen
- Barriers That Contributed to the Event: Communication failures and unsafe home care practices identified
- Nurse Administrator's Role in Identifying Barriers: Administrators assess nursing practice to find causes
- Nurse Administrator's Role in Correcting Barriers: Policy development and safe practice implementation strategies
- Conclusion: Summarizes nurse administrator's dual role in sentinel events
✍️ How to write this paper — guide, tools & examples ▾
What makes this paper effective
- Uses a concrete, specific case example (an elderly COPD patient) to ground abstract concepts in a realistic clinical scenario, making the analysis more accessible and credible.
- Clearly connects The Joint Commission's documented sentinel event data to the case example, demonstrating evidence-based reasoning.
- Maintains a logical, parallel structure throughout — each section on nurse administrator roles mirrors the same problem-solution framework (identify barriers, then correct them).
Key academic technique demonstrated
The paper demonstrates applied case analysis: it introduces a theoretical framework (sentinel events and their causes), presents a real-world scenario, and then systematically applies the framework to analyze how nurse administrators should respond. This technique is particularly effective in health care writing because it bridges policy-level guidance with practical clinical accountability.
Structure breakdown
The paper opens with a definition of sentinel events and their significance, then presents a specific case scenario. It moves into barrier identification, drawing on Joint Commission findings, before dedicating two parallel sections to the nurse administrator's dual responsibilities — identifying and correcting those barriers. The conclusion synthesizes both roles and reinforces the paper's central claim about nurse administrators' importance to patient safety. The structure is straightforward and well-suited to a health care administration audience.
Introduction to Sentinel Events
A sentinel event is defined as an unexpected occurrence involving serious physical or psychological injury, death, or the risk of such outcomes. Serious physical or psychological injury specifically includes the loss of limb or function. Sentinel events appear sporadic, yet they are distinct incidents that can occur regardless of a patient's underlying condition ("Sentinel Events," 2012). However, these events typically reflect deficiencies in hospital systems and procedures that contribute to preventable patient harm. Some of the most common sentinel events include medication errors resulting in death, suicide in inpatient settings, clinical procedures performed on the wrong patient, and maternal deaths. As part of enhancing patient safety and health care quality, nurse administrators play a crucial role in identifying these events, recognizing the barriers that contribute to them, and developing measures to address those barriers.
Sentinel Event Example: Home Oxygen Fire
An 88-year-old male patient has been diagnosed with Chronic Obstructive Pulmonary Disease (COPD) at a local health facility. The patient lives with his adult daughter and her family, which may place them at risk as well due to his condition. He is currently receiving home health care services from a home care provider. As a result of smoking while using supplemental oxygen, the patient caused a sentinel event — a home fire with the potential for serious injury or death.
References
Ballard, K. A. (2003). Patient safety: A shared responsibility. The Online Journal of Issues in Nursing, 8(3). Retrieved August 21, 2015, from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No3Sept2003/PatientSafety.html
"Lessons learned: Fires in the home care setting." (2001, March 1). Sentinel Event Alert. Retrieved August 21, 2015, from
"Sentinel events (SE)." (2012). CAMH Update. Retrieved August 21, 2015, from
Already a member? Log in
Unlock the rest of this paper
135,000+ research papers · AI writing tools · Plagiarism & AI detection
24-Hour Pass
Does not renew
Get 24-Hour PassMonthly
Renews at $12.99/month until canceled
Start MonthlyAnnual
Renews at $99/year until canceled
Start Annual- Unlimited AI writing tools
- Plagiarism and AI text detection tool
Plan details
Unlimited AI writing tools are for individual, non-automated use and are subject to our Terms of Service and abuse-prevention measures.
TextChecker scans: 1 during the 24-Hour Pass, or 5 per month with Monthly and Annual.
Prices exclude applicable tax.
Always verify citation format against your institution’s current style guide requirements.