Introduction
Sentinel events occur unexpectedly within the working areas. When this event occurs, they can lead to serious injuries or deaths at a time. The injuries can be physical or psychological depending on the extent of injury (Valentin et al. 2006). However, the Joint Commission defines sentinel event as any unexpected incident in the health care sector, which can end in demise or solemn physical or mental damage to the patient in place. Nevertheless, sentinel events are not in any case related to the natural sickness of the patient neither the illness result into the occurrence of sentinel events.
The events are identified and indicated in The Joint Commission accreditation policies that help to aid the source investigation as well as assist in the growth process of preventive actions (Grunebaum et al. 2011). A database is developed in the health sector to indicate and show the sentinel events. It also delves into how to keep and to work with the same. However, despite the fact that these sentinel events usually occur, it is possible to prevent them by use of health and safety acts and policies that are introduced in the health sector. Even if the acts or policies cannot end the events from occurring but reduce the rate to which they occur.
Some of the major sentinel events that are reported in most cases are. Delayed treatments to the patient from the nurses of the doctors, wrong-site surgery, medication error, fall, restraint, suicide amongst patients who feel they does not deserve to leave anymore, potential pathogen exposure, wrong prescription of drugs and drug spillage on the floor (Okereafor et al. 2008). The events are termed as a sentinel as the word indicates or shows the need for immediate response to the event that in the case of occurrence.
The ultimate objectives of sentinel event strategy are to have an optimistic influence that enhances improving the rate if patients care treatment and services and can help in reducing sentinel events from occurring. The policy also helps the health sector practitioners to understand factors that contribute to the occurrence of sentinel events (Grunebaum et al. 2011). The policy as well helps in improving the general knowledge of the people on concerning sentinel events regarding their causes, contributing factors and ways or strategies of preventing the event. Hospitals that have and own a sentinel policy hold the highest customer trust and confidence on how they carry out their daily activities.
Identification and definition of problem
The situation becomes more problematic when injuries tend to occur frequently in a working environment. The injuries lead to many problems to both the individuals and society as a whole (Wang et al. 2008). Most of the problems that occur are caused by human error. They are therefore possible to prevent and manage to ensure reduction of sentinel events. These events can as well lead to improper and unexpected physical challenges like deafness. In the process of these, sentinel events occurring, madness can as well erupt (Wang et al. 2008). It is much concern those we the issue of this sentinel should be properly addressed mostly by the use of mitigation measures and preventive actions.
Nevertheless, sentinel events can as well lead to permanent closure of the hospital when the issue becomes rampant and exceeds the management from controlling it accordingly (Wang et al. 2008). Healthcare systems and sectors are the most fragile sectors around, it, therefore, require a lot of attention to development, and earns the confidence of the patients who are the customers (Wang et al. 2008). The management should, therefore, work towards maintaining and protecting the image of the hospital through adequate and required attention. Therefore with the occurrence of these sentinel events; it is much easier to lose the customers trust.
However, the workers of the same institution are as well in a stack. Reduced patients in the hospital mean that the hospital swill has less income (Wang et al. 2008). The issues, therefore, will translate to reduce income to the workers and later entrenching since the healthcare cannot be able to settle the bills (Wang et al. 2008). Therefore, sentinel events, have much and more problems not the patients or workers alone but to the whole society as well. Nevertheless, some of the healthcare always involve themselves in scholarship and helping the society mostly schools.
For this reason, in the existence of sentinel events, the funds will reduce thereby preventing the healthcare from involving themselves in such activities (Wang et al. 2008). The healthcare systems that also receive donations from abroad regarding free drug and finance for development will reduce. The members will feel that the management is poor enough not to deserve the favor of receiving the cash, and therefore the money will be challenged towards other areas and sectors (Wang et al. 2008).
Despite, all these sentinel events are a hindrance to development. Much more money is channeled towards treating the injured people from the event and taking care of their needs (Wang et al. 2008). Of which otherwise, the money could be challenged towards enlarging the word size or rather, installation of warm showers for the patients. Many times, most patients are prescribed a hot shower too, boost their blood pressure, but they cannot access this in the hospital where they are admitted (Wang et al. 2008).
Because of increased sentinel event occurrence in the area, deaths also increase in return. Increased deaths rates reduce the productivity of the society and the general population (Wang et al. 2008). Increased death rates as well lead to reduced gross domestic product of the country as most people and dead and most of the living are elderly (Wang et al. 2008). For these reasons, therefore, it is important to do more research on sentinel events and their preventive measures.
Background literature
A research reviled by Wisconsin Department show that sentinel events were experienced starting a long time ago (Valentin et al. 2006). The exact year when it was experienced first cannot be traced. The issues started when a young woman was reported dead after receiving a dose of an epidural anesthetic as an alternative of penicillin, which was actual to get. The woman, also a teenager, had a seizure a few minutes after receiving a dose in the form of an injection. In less than two hours’ time, the patient was already dead (Grunebaum et al. 2011). The reason behind all these was that the nurse had confused the penicillin bag with the epidural bag, which used.
Therefore, it is evident that sentinel events surely occur and most of which are caused by human error. Nevertheless, information from JCAHO tends to cover incidents that are reviewed by the organization (Okerefor et al. 2008). However, not all the cases of sentinel event cases are reported most of them go unreported as people consider them small. Some of the reasons that are stated as leading to a low rate of reporting cases associated with sentinel events are fear of punishment, lack of time and misperception concerning the brutality of actions, which require attention and notification (Websiter et al. 2011).
Consequently, the incidence of a sentinel event is much higher that it is. However, fortunately, enough, most errors cause no serious harm, and the cost of the sentinel event that exists is substantial. The research shows that each preventable adverse drug event costs a clinic around $ 8,750 per year (Valentin et al. 2006). However, a sector of the medication-related damages is preventable as the research indicates by use of computerized systems and methods (Okerefore et al. 2008).
Experts of the same approve that today’s nurses, doctors, pharmacists and other medical staff are highly trained, and therefore the rate and mood of medical services are highly improved the medical field (Grunebaum et al. 2011). The problems of sentinel events occurrence are therefore fully blamed on human error. The abandoning policy that distillates on guilt is at the emotion of the developments in the state of enduring protection which is mainly planned in most of the reports (Connelly 2012). Therefore, to end the problem of sentinel events the management should stop blaming it on people but rather find the way forward towards solving the problem. The hospital should, therefore, set trendy place a continuation plan to re-evaluate the technique occasionally.
Most of the hospitals now have electronic ordering and labeling system in place (Newton 2014). However, only a few physicians use them in their daily activities. The problem now begins here; that is why we say sentinel events are more human-caused rather than naturally caused. Most of the doctors are as well informed of what is happening in other areas and the existence of advanced systems and equipment (Wang et al. 2008). For this reason, therefore, the following should occur in a healthcare facility.
Evaluate different treatment options.
Assess the patient names and purposes of all medications
Examine the patient’s medication list routinely and during care transactions.
Confer when and how to take the medication.
Converse drug-drug, drug-food, and drug-disease interactions
Analyze the patient’s role in appropriate medication use,
Appraise the role of medications in the overall context of the patient’s health.
However, it is bad to understand that sentinel events still take a staggering human and economic toll (Grunebaum et al. 2011). Despite all this, there is improved statement, new skills and perchance-true breadwinner and hospitals play a key role in this (Websiter et al. 2011). Tentatively, more studies should be carried out to indicate and show more intimacy and persistence on the same.
Causal factors
Causal factors are any omission, deficiency or behavior that when omitted, eliminated or avoided could probably prevent the occurrence of the sentinel events (Newton 2014). The causal factors, therefore, helps in minimizing the occurrence of the events. There are many ways and factors that when put in practice can reduce or prevent the sentinel events from occurring (Newton 2014). Some of these related causal factors in healthcare centers that when implemented can prevent the occurrence of sentinel events are:
Existence of barriers along the pathway around where the patients are to prevent frequent fall of the patients
Recruitment of poorly learned with low experience personnel in the pharmacy sector leading to wrong prescription and treatment of patients.
The presence of holes around the compound that can lead to accidents around the area
Improper and inadequate equipment to be used during the surgery process
Improper usage of laboratory equipment and chemical: Lack of rules governing the laboratory as well indicating guidelines to the users
Employment of inadequate employees and personnel is increasing the rate of them being tired.
Probable root cause
Just like any other situation, sentinel events has their root cause to even an e=sentinel event that occurs. The situation gives an elaborate idea of how the event happened, where and how and what lead to it being as it is. Therefore, to causal factor there is a probable root cause to it. Nevertheless, root causes are determined by use of a root cause analysis. The analysis help in determining and identifying the root causes (Webster et al. 2011).
Hence, root cause analysis is a method of solving problems that is used in the process of identifying the root cause. In this case, therefore, as a factor is considered a root cause if it is removable from the problem prevents the final occurrence of the undesirable event from occurring. Root cause analysis (Connelly 2012) is, therefore, a procedural step and idea that involves step by step decision to perfect the working (Webster et al. 2011). These steps include identifying the problem, gathering required data and evidence, identification of cause related to the factors aligned, categorize the causes into either causal factor or root causes (Connelly 2012). Separate and eliminated the harmful factors. Therefore the probable root causes are:
Knocking oneself against the barriers in the paths.
Presence of holes in the patient section
Low payment to the practitioners
Inadequate personnel working in the health sectors due to low and shallow skills provided to them in the learning institutions.
Poor management of the health care officials and the management commission
Poor cleaning of the floor is leaving the floor with spills, which make the surface slippery.
Implementation of the solution
However, the hospital cleaners should ensure that any spill that occurs on the floor is removed as soon as it occurs to avoid the presence of spills on the floor. Any sharp object that can cause injury along the pathway including in the washrooms should be removed as soon as possible to enhance proper and minimized cases of sentinel event occurs in the area. These solutions should be implemented by the management by ensuring that every individual in the area is performing his or her duty as described in the job description sheet. The workers should as well be responsible for themselves and the patients as a whole.
Conclusion
References
Connelly, L. M. (2012). Cause analysis. Medsurg Nursing, 21(5), 316.
Grunebaum, A., Chervenak, F., & Skupski, D. (2011). Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events. American journal of obstetrics and gynecology, 204(2), 97-105.
Newton, I. (2014). The recent declines of farmland bird populations in Britain: an appraisal of causal factors and conservation actions. Ibis, 146(4), 579-600.
Okereafor, A., Allsop, J., Counsell, S. J., Fitzpatrick, J., Azzopardi, D., Rutherford, M. A., & Cowan, F. M. (2008). Patterns of brain injury in neonates exposed to perinatal sentinel events. Pediatrics, 121(5), 906-914.
Valentin, A., Capuzzo, M., Guidet, B., Moreno, R. P., Dolanski, L., Bauer, P., & Metnitz, P. G. (2006). Patient safety in intensive care: results from the multinational Sentinel Events Evaluation (SEE) study. Intensive care medicine, 32(10), 1591-1598.
Wang, T. D., Plaisant, C., Quinn, A. J., Stanchak, R., Murphy, S., & Shneiderman, B. (2008, April). Aligning temporal data by sentinel events: discovering patterns in electronic health records. In Proceedings of the SIGCHI conference on Human factors in computing systems (pp. 457-466). ACM.
Webster, L. R., Coachella, S., Dasgupta, N., Sakata, K. L., Fine, P. G., Fishman, S. M., & Peppin, J. (2011). An analysis of the root causes for opioid‐related overdose deaths in the United States. Pain Medicine, 12(s2), S26-S35.
