The nurse is reviewing research articles about ‘sentinel events’ in health care.
Which is an example of a ‘sentinel event?”.
A.
The nurse mistakenly calls the patient’s daughter “your wife.”.
B.
A surgical procedure performed on the wrong leg of a patient.
C.
The surgical procedure is postponed by 30 minutes.
D.
The nurse fails to raise the bed to a working height during patient care.
The Correct answer and Explanation is:
The correct answer is B. A surgical procedure performed on the wrong leg of a patient.
Explanation:
Sentinel events are critical incidents that result in significant harm to patients and are considered preventable with proper protocols and safety measures. These events are of such severity that they signal a need for immediate investigation and corrective actions to prevent future occurrences. The term “sentinel” implies that these events serve as a sentinel or warning to identify and rectify systemic problems within healthcare systems.
Option B describes a surgical procedure performed on the wrong leg of a patient. This is a classic example of a sentinel event because it directly results in serious patient harm and signifies a failure in multiple safety checks and protocols. Such events are often categorized under “wrong-site surgery,” which is a serious breach of patient safety. These occurrences usually trigger thorough investigations by healthcare institutions, followed by comprehensive reviews and revisions of procedures to prevent recurrence.
Option A involves a nurse mistakenly calling the patient’s daughter “your wife.” While this mistake might cause confusion or distress, it does not result in direct harm to the patient and does not meet the criteria for a sentinel event. This type of error, while important to address for improving communication, is not classified as a sentinel event.
Option C refers to a surgical procedure postponed by 30 minutes. Although delays can impact patient care and scheduling, a 30-minute delay does not typically constitute a sentinel event unless it leads to significant harm or complications for the patient. In most cases, delays are managed within the context of patient safety protocols and do not signal a critical failure in safety systems.
Option D involves the nurse failing to raise the bed to a working height during patient care. While this error can potentially lead to patient injury, such as falls or strain, it does not immediately meet the definition of a sentinel event unless it results in severe, preventable harm. This type of error would be addressed through routine quality improvement processes rather than being categorized as a sentinel event.
In summary, sentinel events are severe incidents that indicate a failure in safety procedures and require immediate corrective actions. Option B exemplifies such an event due to its direct impact on patient safety and its need for systemic review and improvement.