Sentinel Event Issues: Scholarly Articles

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Sentinel Event Issues: Scholarly Articles


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Complete the Sentinel Event activity.

Research at least three scholarly articles related to issues raised in the sentinel event and how they were addressed.

Write a 700- to 1,050-word paper based on your research that:

  • describes the sentinel event;

  • identifies the barriers in communication or health care practices that occurred in this event; and

  • explains the nurse administrator’s role in identifying and correcting the barriers that caused this event. Include the risk analysis and/or root cause analysis.

Include a reference list for all sources cited.

Format your paper and reference list according to APA guidelines.

Click the Assignment Files tab to submit your Sentinel Event Issues: Scholarly Articles assignment, practicum hours log, and applicable practicum activity deliverable(s).

HSN 525 WEEK 6 Creating a Process for Analysis

This assignment is designed to help you analyze data, and developing a process is a key part of that task. Part of this analysis is using

Sentinel Event Issues Scholarly Articles

Sentinel Event Issues Scholarly Articles

the data collected during your risk assessment phase.

Review the data collected from your risk assessment.

Research at least three resources that will help guide you in analyzing, developing, and implementing your data into a workable plan.

Create a matrix that organizes your research and provides the following:

  • A review of the data
  • Whether the data is qualitative or quantitative and your rationale
  • A process for analyzing your data
  • A plan to integrate the data in to your change project

Include an APA-formatted reference page for all sources cited.

Click the Assignment Files tab to submit your assignment, practicum hours log, and applicable practicum activity deliverable.

HSN 525 WEEK 5 Internal and External Forces of Change

It is important to be able to identify internal and external forces that might impact the planned implementation of an organization change project. This assignment allows you to explore communicating your proposed change through media. By making a podcast, you must be able to briefly outline your proposed change, account for internal and external forces, and provide strategies for overcoming any obstacles.

Explore your topic through the lens of an organization that faced similar challenges.

  • What were some of their driving and resisting forces to change?
  • How did they address the internal and external challenges?
  • Is there any way they responded that would be applicable to your topic?

Research various podcast sources like How to Podcast tutorial.

Create a 3- to 5-minute podcast summarizing what you learned and why it is significant to your project.

Include a transcript of your podcast, and an APA-formatted reference page.

Click the Assignment Files tab to submit your assignment, practicum hours log, and applicable practicum activity deliverable.


What Kinds of Sentinel Events Are There?


sentinel event, from the standpoint of facility, could be fall or the breakdown of equipment that is part of the routine building function. 
Failure of room outlets to give oxygen or inlets to provide appropriate vacuum to patient are examples of this.


The most prevalent causes of sentinel events in healthcare, according to the Joint Commission, include inadvertent retention of foreign item, fall-related incidents, and conducting treatments on the wrong patient. 
Delays in treatment, pharmaceutical errors, and fire-related accidents are among the others.


The Joint Commission will begin include definition for fall events in its Sentinel Event Policy on January 1, 2021. 
This is being done to assist personnel in all healthcare settings in determining whether or not fall should be considered sentinel event.


It will read as follows:


Fall occurrence – fall that results in one or more of the following: 
any fracture; surgery, casting, or traction; required consult/management or comfort care for neurological (for example, skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib fracture, small liver laceration) injury; or patient with coagulopathy who receives blood products as result of the fall (not from physiologic events causing the fall). 


Sentinel Events Most Frequently Reported (1st Half of 2020 Statistics)


The Joint Commission looked into 437 sentinel incidents in the first six months of 2020. 
An accredited or certified entity self-reported the bulk of the events (372 in total, or 85 percent).




The Joint Commission is the source of information.


The following were the most commonly reported types of sentinel incidents from January to June 30:


Administration of care


Invasive or surgical techniques


At the time of the report, there were no events assigned to them.


Events to Prevent Suicide


Environment-related incidents


Device or product


When confronted with Sentinel Event 
Face-to-face (What to Do When an Event Occurs)


What should you do next, according to the Joint Commission, is five-step process.


“Take With the Joint Commission: What to Do When Sentinel Event Occurs” includes advice from Patricia McColl, RN, patient safety specialist at The Joint Commission’s office of quality monitoring and patient safety, on what to do if your organization experiences sentinel event.


Step 1: Safeguard the situation by ensuring the patient’s and staff’s well-being.


Step 2: Save any items that may be useful in the inquiry, such as equipment, tubing, and prescriptions.


Step 3: Tell the patient or caregiver about the problem and any pertinent facts.


Step 4: Assist the patient, his or her family, and the staff.


Step 5: Comply with The Joint Commission’s reporting and root-cause analysis requirements, as outlined in the accreditation manual. 
After the sentinel event, root-cause study should be done as quickly as possible.


The five-step approach aids in the improvement of care, treatment services, and the prevention of future catastrophes.


Rather than individual achievement, it emphasizes factors and underlying causes, conditions, and so on.




What to Do When Sentinel Event Occurs (Take 5)


What are the TJC’s Sentinel Event Requirements?


The Joint Commission has comprehensive program in place to detect and document these sentinel incidents so that they may be addressed and others in the healthcare industry can be warned to prevent similar issues.


Their routine necessitates:


systematic team reaction that stabilizes the patient, informs the patient and family about the incident, and offers support to both the family and the personnel involved in the incident.


Notification of the hospital’s management


Immediate inquiry is required.


Sentinel Event vs. Patient Safety Event


patient safety event is an occurrence, incident, or situation that may or may not have caused harm to patient. 
This occurrence can be caused by defective system or process design, system breakdown, equipment failure, or human mistake, however it is not always the case. 
Adverse occurrences, no-harm events, close calls, and dangerous conditions are all examples of patient safety incidents.


Each hospital must have clear patient safety plan that is disclosed to all employees, including what occurrences are considered sentinel and what situations are deemed patient safety events.


TJC expects the hospital CEO to produce these strategies and demonstrate that steps have been taken to:


Describe the circumstances around the incident.


Who was involved, and what equipment was used?


In what ways will the accident or event be avoided in the future?


Similarly, the plan should specify:


Who is in charge of repairing the equipment or following the procedure?


When will the repair be finished?


How will this planned repair or procedure change prevent future problems?


How can the TJC and patients be sure that the fix will be implemented?




Sentinel incidents are being reported by organizations to aid in the identification of relevant factors and actions that healthcare institutions can take to decrease risk and improve quality.


Although most hospitals strive to offer safe and effective care for their patients, accidents and anomalies can occur. 
To preserve and exceed patient safety, healthcare facilities and organizations are using an integrated approach.
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