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Sentinel Events and Role of Nurses

Sentinel events are described as unexpected occurrences which may result in serious physical and psychological injuries or even death (Frain, Murphy, Dash, & Kassai, 2004). Nursing care brings about interventions like hand washing before attending to patients to avoid hospital acquired infections (HAIs). Nurses ought to survey and identify activities that most likely lead to deaths or unexpected loss of function caused by an infection during care and treatment. This essay will explore the role of nurses in analyzing sentinel events and how to avoid infections to patients in the healthcare facilities.

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The New Zealand Quality Improvement Committee report (2009) stipulates that to move towards the best practice solutions, voluntary reporting by clinicians is essential. Thus, nurses who are directly involved with patients ought to create safe environments for patients, by alleviating practices that would result to HAIs. Further, nurses are responsible for reporting the eventuality of any sentinel event that may arise affecting the recovery of a patient. The reporting serves as a guide in the future towards improving the means of ensuring quality health and safety to patients. Critical analysis of sentinel events enhances medication safety since medication errors which are relatively common are detected and rectified in time. Wang et al. (2008) argue that aligning medical or health data with sentinel events could play a significant role in revealing the cause and effect. By utilization of the acquired health data, nurses can realize patterns of patients’ health history, as well as spot precursor events like stress that may trigger a recurrence of mental problems. For example, in case a patient experienced three heart attacks at various intervals during the treatment period, it would be difficult to identify the cause and subsequently come up with interventions to prevent any future similar occurrences without utilizing prior health history of the patient.

Patient’s safety is an approach that ensures nurses understand reasons or causes of harm that occur to patients. Further, nurses are mandated with the role of ensuring solutions are put in place to avoid similar mistakes in the future (Flicek, 2012). Nurses play a critical role in patient safety bearing in mind that they have the capacity and experience to ensure the wellbeing of patients. However, communication barriers may hinder the effective realization of patient safety. O’Daniel and Ronstein (2008) argue that for effective clinical procedures to be achieved critical information must be well communicated to physicians, nurses and other medical practitioners involved in the care of patients. Lack of effective communication affects the efficiency of practice among nurses and physicians, results in poor quality of care, as well as mistakes in the treatment process affecting the patient’s recovery process.

The Quality Improvement Committee (2009) states that communication errors are the leading causative factors of sentinel events. Hence, practices among nurses that promote effective communication are paramount to alleviate eventuality of sentinel events. Flicek (2012) stipulates that communication is the most identified cause of sentinel event, and with improvement, better patient outcomes are achieved. Nurses have the role of ensuring that they put more efforts to promote effective communication among their peers, as well as other medical practitioners to promote quality of care. Further, communicating with relatives of a patient is expected to be conducted in a manner that does not affect their psycho-social well-being. Tang, Chan, Zhou and Liaw (2013) argue that with effective communication, quality care, and patient safety is assured resulting in reduced mortality rates in the health domain.

Collaboration among health practitioners working together is inevitable as it promotes effective communication and evidence-based practice (O’Daniel & Rosenstein, 2008). A key example of decreased collaboration is in the case where nurses feel they lack self-rule, whereas physicians are frustrated by the nurses’ behavior of not carrying out tasks appropriately. This dissatisfaction may affect the quality of care delivered to the patients. Thus, the relationship between nurses and physicians is not supposed to bring about communication barriers to ensure high quality of care to patients.

Identifying the cause of a sentinel event is necessary to curb their future occurrence. The cause analysis is a process whereby the causal factors underlying a sentinel event are identified (Wang et al., 2008). This analysis should not just focus on individuals involved, but also should look into the failure of the processes and systems put in place. The aim is to identify the problem and come up with a more efficient and improved system that would ensure the reduction of the likelihood of such events occurring in the future (Frain et al., 2004). To carry out an effective analysis, nurses should come up with questions that search answers on what the event was, who was involved, the place of incidence, why the event occurred and the procedures breached.

In conclusion, sentinel events are critical in nursing as they act as indicators of areas where attention is needed to improve the quality of care. Effective communication among nurses and the physicians has been shown to result in decreased probabilities of mistakes during nursing practice. Thus, sentinel events should be investigated, solutions implemented and evaluated over periods of time so as to avoid future recurrence of errors.

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Flicek, C. L. (2012). Communication: A dynamic between nurses and physicians. Medsurg. Nurs. 21(6), 385-387.

Frain, J., Murphy, D., Dash, G., & Kassai, M. Association for Professionals in Infection Control and Epidemiology. (2004). Integrating sentinel event analysis into your infection control practice. Washington, DC: APIC.

O’Daniel, O.H., & Rosenstein H.A. (2008). Professional communication and team collaboration. In R.G. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (pp. 1-14). Rockville, MD: Agency for Healthcare Research and Quality.

Tang, C., Chan, S., Zhou, W., & Liaw, S. (2013). Collaboration between hospital physicians and nurses: An integrated literature review. International Nursing Review, 29(3), 223-229.

The Quality Improvement Committee (2009). Sentinel and Serious Events in New Zealand Hospitals 2007–2008. Wellington: The Quality Improvement Committee.

Wang, T.D., Plaisant, C., Quinn A.J. Stanchak, R., Murphy, S., & Shneiderman, B. (2008). Aligning temporal data by sentinel events: Discovering patterns in electronic health records. New York: ACM.

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