Free Essay: Sentinel Events

Published: 2023-08-27
Free Essay: Sentinel Events
Type of paper:  Essay
Categories:  Medicine Audit Community health Customer service
Pages: 7
Wordcount: 1876 words
16 min read

In the paper, focus is made on sentinel events as they happen in Nightingale Community Hospital: indicated in the audit. It can be understood that sentinel events, as described by the healthcare accreditation organization, The Joint Commission, are the unexpected events that occur in a healthcare institution and results in serious psychological or physical injuries or even death to the patients, and are not related to the natural causes of the illnesses of patients. As such, they are accidents that happen in the healthcare institutions and deteriorate the conditions of the patients being attended. They can be milder, moderate, similar, or even worse than the natural cause of patient discomfort. Their root cause analyses help in unearthing their causes, which further directs on the measures to be put in place to curb them from recurring into the future.

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Thus, following the audit conducted on the activities occurring in Nightingale Community Hospital, a sentinel event involving a child abduction occurred. It happened that there was a mother who took her child to the hospital to undergo some surgery procedure. Her child, named Tina, was the patient in such a case. Thus, once in the hospital, a pre-op nurse discussed with the mother on the processes involved in the treatment of patient. Since the mother had a different appointment to attend to, she had to understand the duration in which the treatment process was to take. As such, the pre-op nurse explained to her that once the patient, Tina, went to the operation room, her surgery would be taking a region of forty-five minutes. Then, she would be taken to the recovery room with nurses to provide her with a series of care as she normalizes to the extent of going home for home care. In the recovery unit, the patient would take a minimum of one hour as explained by the pre op nurse. The explanations could then inform the timing of the mother who would gauge the time to be back from where she was to attend. Tina’s mother was the only one accompanying her to the hospital, hence she was also responsible for taking her home once the treatment services were offered, as required by the policies of the hospital. The mother, as a reply, informed the pre-op nurse that she would return for Tina once she was in the recovery section, such that she left for a quick errand once the patient was taken to the operation room. Everything went on well. The mother had given the pre-op nurse her contact information in case any communication was needed. The mother demanded that the nurse contact her once Tina was out of the operation room and was now in the recovery section sooner than expected.

After the stipulated time, Tina’s mother came back for her child. She came after 2.5 hours, and found that the patient had been discharged thirty minutes earlier. Thus, she came right on time for Tina. However, she found that the unexpected had happened, which now characterized sentinel events in the hospital. It was found that Tina’s father had come for her, taking her to his home to await the mother to arrive. In such a scenario, there was the violation of the procedures and policies of the healthcare institution in dealing with the patient, where the person bringing her to the hospital is responsible for her fate including taking her back home. Tina’s mother raised an alarm since she had not found her child, who she suspected had been abducted. As a result, the sentinel event that took place was referred to as child abduction. Tina, thus, had been abducted by her father.

In the alert raised by Tina’s mother, the security personnel were attracted using contingency alert equipment and resources, the ‘’Code Pink’’ that had been activated. The security personnel of the hospital contacted local law enforcement. Following the interview of Tina’s mother by the security personnel, she informed them of her single mother nature. Therefore, she had been divorced by her husband, and thus was the one with the full custody of the children, including Tina. The security personnel searched for Tina and found her in her father’s house. She was found thirty minutes later. Thus, it was a case of child abduction since Tina’s father was not responsible for their custody. Therefore, there was an error in the process of handling the patient by the owners, such that a wrongful individual was allowed to take custody of the patient who had been left by a different custodian during admission.

During the sentinel event, there are some personnel present at the time. They include the pre-op nurse, Chief Executive Officer (CEO) of Nightingale Community Hospital, security personnel, post-op nurse, OR physician, and department management. They have different roles and responsibilities that cumulatively result in the smooth functioning of the healthcare institution. starting with pre-op nurses, they were three in number. As can be observed in the occurrence of the sentinel event, a pre-op nurse was the one who ushered in the patient, Tina, and her mother. They engaged in some communications as the patient awaited the actual surgery. Therefore, pre-op nurses provide information regarding what the patient is to expect during surgery. Such information include the duration of the surgery operation and the time the patient will be taken to the recovery unit Joint Commission on Accreditation of Healthcare Organizations (Centers for Medicare & Medicaid Services & Joint Commission, 2019). The information is essential for both the patient and the custodian to prepare psychologically. The patient will be able to understand the duration of the forthcoming activity and prepare accordingly. For the custodian to the patient, knowing the duration that the patient is expected to take in the operation room and the recovery section will make him understand the timing of the forthcoming events, and prepare accordingly both emotionally and psychologically.

Besides, the pre-op nurse is responsible for the motivation and emotional preparation of the patient awaiting surgery procedures. It can be established that the patients awaiting to undergo some procedures can be preoccupied by stresses on what is being anticipated. As such, the patient is supposed to be composed before undergoing the procedures, which will then facilitate peaceful operations by the physicians in the operating room. Pre-op nurse, therefore, is there to ensure that the patient is readily prepared emotionally and psychologically for the treatment.

Furthermore, the pre-op nurses performs the activities that will see to it that the principles of preoperative assessment are adhered to. One of such principles is that of the identification of the patient’s medical, spiritual, and psychological needs before the surgery. There is also the principle of communicating, where appropriate, with the external agencies and entities for the implementation of discharge planning (Joint Commission Resources & Joint Commission International, 2012). Finally, there is the principle of ensuring that there is a more effective usage of the hospital resources. Such resources include theatre time alongside bed occupancy. It is done through the reduction of the number of patients who are not attending scheduled surgery, total number of cancelled operations, as well as the length of the time spent by the patients in the hospital (Centers for Medicare & Medicaid Services & Joint Commission, 2019). In the end, there shall be a positive impact on the waiting lists. In the preoperative assessment, the pre-op nurse performs a clinical assessment in appraising the health of the patients to ascertain that he is fit to undergo some anesthetic in the planned operations. Hence, the nurse is greatly tasked in the preparation of the surgery patient for the operation.

With respect to medical history of the patient, pre-op nurse is tasked with taking a full medical history of the patient. Particular attention is taken to any complications that might have occurred in any previous operations. In the event they get indicated, there shall be the performance of appropriate tests such as x-ray, blood test, and electrocardiogram. In addition, when any abnormalities get detected, they will be addressed by the appropriate healthcare professionals as advised by the pre-op nurses (Centers for Medicare & Medicaid Services & Joint Commission, 2019). The pre-op nurses and the anesthetists can also discuss them, and if possible surgery operations get deferred.

Besides, pre-op nurses design discharge planning. The activity is a social aspect for the wellbeing of the patient, alongside the factors that can potentially affect his discharge from the healthcare institution, including transport, the inclusion of social services, the psychotherapists, the occupational therapists, or even the community care being provided to the patient. Therefore, the preoperative assessment provides an opportunity for the pre-op nurses to prepare the discharge arrangements necessary in ensuring a smooth return of the patient being handled to the community.

Furthermore, there is a perioperative nurse. Her purpose is exclusively to ensure that she provides care to the patient recovering after the surgical operations. The nurse ensures that the patent is stable and prepares the room for the team of patients that follow. Following the transfer of patients to recovery room, the nurses care for them until their release from the healthcare institution.

There are also the roles played by the nurses in the operating room, immediately after surgery. They count all the things ranging from sponges to the surgical tools to make sure that there is an accounting for everything, for the benefit of efficient stocktaking. In the event they locate any discrepancy, they must establish whatever happened to the items that can be missing. They also take part in the sterilization and clearing away of the surgical tools used (Centers for Medicare & Medicaid Services & Joint Commission, 2019). They also remove the drapes that were used to cover the patient during the surgical operations. They, moreover, have the responsibility of disposing of the medical wastes besides preparing the samples that were taken from the patients during testing. Finally, they take part in cleaning the operating room while restocking the supplies in such a way that the room will be ready for the surgical operations of the teams that follow.

In Nightingale Community Hospital, the physician who took part in the surgical operations of Tina, the patient, was also present. He is referred to as an operating department practitioner. The practitioner serves as a director of the operating theatre. He also takes part in surgery whereby there is the diagnosis as well as the treatment of various medical issues faced by the patients. They have specialized education and the experiences that range from general surgical needs to the cardiothoracic issues. They, further, direct and manage all the staff in the operating rooms, hence are responsible for the outcomes of the patients who were being attended to. As observed, the patient operating in the room where Tina had been admitted to was responsible for whatever outcomes that befell her after the surgery and recovery processes.

The surgeon also ensure that the sterile field remains intact, that the patient is tolerating the surgical procedure, and also that the surgical team he is collaborating with is working optimally for the benefit of excellent outcomes in the patient being treated. He must, besides, have the capability to maintain the composure alongside managing any crisis that could arise in the operating room.

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