Sentinel events “are complicated situations in healthcare institutions that can result in loss of limb or even death” (Athanasakis, 2012, p. 779). They can also lead to serious physical or psychological injuries. Nurse Administrators (NAs) and caregivers should use their skills to address such events. They should embrace the best concepts and steps in order to prevent such events from happening (Vogelsmeier, 2011). A young lady died in our hospital due to general sepsis of MRSA after appendicitis surgery (Gordon & Lowy, 2008). This discussion gives a detailed analysis of this sentinel event.
Description of the Sentinel Event
Healthcare workers should be careful whenever administering various medicines to their patients (Athanasakis, 2012) or doing simple patient care at their bedside. A sentinel event occurred in our healthcare facility whereby a young patient was having a surgery. The patient was infected with generalized Methicillin-resistant Staphylococcus aureus (MRSA) because of a number of factors (Gordon & Lowy, 2008). For instance, one of the nurses did not use gloves to check and change an IV. As well, a relative of another patient wearing contaminated gloves touched the corner of the nurse’s station. As well, one of the doctors who saw the nurse manipulate the IV dressing without gloves failed to speak up.
Barriers in Communication and Healthcare Practices
The absence of active communication channels or platforms is something that can result in sentinel events in an organization (Su, 2013). Several gaps in communication were observed during this event. To begin with, the healthcare providers in the institution failed to embrace the best communication practices. This fact explains why the caregiver did not get the required information from the Charge Nurse. As well, the bedside nurse and the physician failed to communicate properly at the right time.
The occurrence of this healthcare event shows clearly that the caregivers in the institution were no longer communicating effectively with their patients. Nurses and doctors should always “interact with their patients if they are to offer quality care” (Karavassiliou & Athanasakis, 2014, p. 37). One of the best practices towards achieving this goal is by promoting the best communication channels. The nurses and caregivers in the facility were not ready to develop the best decision-making processes. The presence of poor communication makes it hard for caregivers to interact with their workmates and patients. This malpractice can affect the health outcomes of more clients.
As well, this sentinel event exposed some of the poor health practices existing in the facility. For instance, the institution was no longer promoting the concept of patient-centered care. This concept encourages caregivers to interact with their patients (Frith, Anderson, Tseng, & Fong, 2012). They should also liaise with the patients’ relatives who help on the daily patient care. Continued collaboration is another effective practice whereby different stakeholders in a health institution focus on the best practices. The method supports the health needs of different patients.
Nurse Administrator’s Role
The institution’s NA undertakes a broad range of activities to prevent the occurrence of various sentinel events. For instance, the NA always encourages different caregivers to work as a team, mentor each other, and focus on the best health outcomes. The administrator also promotes positive decision-making processes. This practice has the potential to identify various weaknesses and present new suggestions that can support the targeted patients (Karavasiliadou & Athanasakis, 2014). However, the above sentinel event occurred despite the efforts undertaken by the NA.
This sentinel event became a wake-up call for different stakeholders in the institution. The NA used an influential Risk Analysis (RA) approach to address the problem. To begin with, the NA identified the major risk factors capable of causing this error (Frith et al., 2012). The NA also identified possible challenges that might have led to the event. For instance, cases of poor communication, reduced morale, and inappropriate actions were observed. Some malpractices such as lack of hand-washing were noticed in the healthcare facility. As well, some of the caregivers failed to embrace the best nursing concepts and practices. Such malpractices explain why this fatal case occurred in the service. The second step was to identify the individuals who were harmed by the error (Gordon & Lowy, 2008). The NA evaluated the risks associated with different persons involved in the case and offered the best findings. The NA observed that inappropriate practices at the workplace led to the error.
The final step was to consider the best approaches that could be used to correct the error. The first proposal was to inform more practitioners about the importance of proper patient care and hygiene in the post-operative department. The caregivers were also encouraged to promote the best communication practices. Patients and medical practitioners should always form powerful teams in order to produce positive health outcomes (Gordon & Lowy, 2008). The NA seemed to understand the importance of monitoring the infection control program (ICP) at the hospital. Such measures should always be undertaken to prevent such sentinel events.
Reference List
Athanasakis, E. (2012). Prevention of medication errors made by nurses in clinical practice. Health Science Journal, 6(4), 773-783.
Frith, K., Anderson, E., Tseng, F., & Fong, E. (2012). Nurse Staffing Is an Important Strategy to Prevent Medication Errors in Community Hospitals. Nursing Economics, 30(5), 288-294.
Gordon, R., & Lowy, F. (2008). Pathogenesis of Methicillin-Resistant Staphylococcus aureus Infection. Clinical Infectious Diseases, 46(5), 350-359.
Karavasiliadou, S., & Athanasakis, E. (2014). An inside look into the factors contributing to medication errors in the clinical nursing practice. Health Science Journal, 8(1), 32-44.
Su, I. (2013). Medication Errors: Will Punitive Measures Help to Decrease the Occurrence: A Case Study. Nursing and Health, 1(2), 12-20.
Vogelsmeier, A. (2011). Medication Administration in Nursing Homes: RN Delegation to Unlicensed Assistive Personnel. Continuing Education, 2(3), 49-55.