Running head: PREVENTING SENTINEL EVENTS
Patient Safety: Preventing Sentinel Events
Kim Peterson
Ferris State University
PREVENTING SENTINEL EVENTS
2
Abstract
Addressing patient safety is a complex and serious issue for the entire healthcare industry. Due
to daily medical errors, healthcare is an unsafe atmosphere and continues to cause harm to
patients. The goal of decreasing harm to patients requires interventions and teamwork to
implement a culture of change within each healthcare organization. Providing safe healthcare
involves a team committed to providing patient centered care. Many of the preventable medical
errors occur mostly from human error, breakdown within the system, and lack of
communication. Problematic areas in healthcare include medication errors, hospital acquired
infections, falls, and pressure ulcers. Teamwork is essential to patient safety and registered
nurses need to be involved. To improve patient safety, registered nurses play a critical role in
addressing the problem and creating change. Registered nurses are involved in the majority of
patient’s healthcare; therefore, nurses in leadership roles are essential to improve healthcare.
The profession of nursing is required to continue education, apply evidence-based practices, and
communicate effectively to advocate for patients.
Keywords: patient safety, preventing medical errors
PREVENTING SENTINEL EVENTS
Preventing Sentinel Events
Every day, errors are made in the healthcare systems that have a negative impact on
patient safety. Some of these errors are considered near misses and some, unfortunately, are
classified as sentinel events. “A sentinel event is a patient safety event, not primarily related to
the natural course of the patient’s illness or underlying condition, that reaches a patient and
results in death, permanent harm, or severe temporary harm requiring an intervention to sustain
life” (The Joint Commission). Patient safety is a serious issue within the healthcare system and
continues to need improvements. Developing a safer environment for patients requires
teamwork, communication, and leadership. Utilizing these elements will improve patient safety,
especially with registered nurses at the forefront of healthcare. Registered nurses are the key
factor in creating a culture of change for patient safety.
The Importance of Patient Safety
The Institute of Medicine (IOM) defines patient safety as “freedom from accidental
injury; ensuring patient safety involves the establishment of operational systems and processes
that minimize the likelihood of errors and maximize the likelihood of intercepting them when
they occur” (IOM, 2000, p. 1). A report issued by the IOM, “estimated 44,000 to 98,000 patients
die in hospitals each year due to medical errors” (2005, p. 1011). In 2013, an article published
by the Journal of Patient Safety estimated over 400,000 patient deaths related to medical errors
(James, 2013, p. 127). The number of sentinel events is appalling and unacceptable. Immediate
interventions to create a system of safety require medical professionals to identify risks,
preventable actions, and act accordingly to these findings.
“In an attempt to improve patient safety, millions of dollars have been invested in the
healthcare system” (McCannon & Berwick, 2011, p. 1). The healthcare industry continues to
3
PREVENTING SENTINEL EVENTS
4
urge for improvements with education and technology for medical facilities to improve the safety
of patients (McCannon & Berwick, 2011, p. 1). However, despite the efforts and expenditures,
the industry continues to struggle with patient safety. According to Akanksha Jayanthi’s article,
10 Top Patient Safety Issues for 2015, hospital acquired infections, hand hygiene, health
technology, medication errors, and transitions of care are some of the safety issues affecting
patient care (2014). Together with education and technology, communication and leadership
amongst medical professional are vital tools to improving quality care. Addressing the top
patient safety issues requires professionals to work as a team to improve the quality and safety of
medical care.
Theory Base
Florence Nightingale and her environmental theory focus on the care of the patient and
providing safe healthcare (Nursing Theory, n.d, para 3). “Nightingale conducted some of the
earliest nursing studies on the factors influencing the safety of patient care” (Ballard, K., (2003,
para. 15). In her book, Notes on Hospitals she states, “it may seem a strange principle to
enunciate as the very first requirement in a hospital that it should do the sick no harm”
(Nightingale, 1863, para 1.) Throughout her own experiences of adverse events in healthcare,
she learned about what worked in order to provide safe healthcare (Nursing Theory, n.d, para 3).
She advocated for safe care and believed nurses had to have the ability to put the patient in the
best conditions available (McNamara, 2011, p. 614). Nightingale encouraged nurses to expand
the base of medical knowledge and use resources to promote patient safety and patient advocacy
(McNamara, 2011, p. 614). Nightingale aimed to “provide a safe and caring environment for her
patients while promoting patient health and well being” (Selanders, & Crane, 2012, para. 1).
PREVENTING SENTINEL EVENTS
Change Theory
Incorporating Ronald Lippitt’s theory of change into the healthcare field may help
promote a positive atmosphere for change. To improve patient safety, changes must occur
within the healthcare industry and the professionals involved with patient care. The definition of
the theory of change“ is the product of a series of critical thinking exercises that provides a
comprehensive picture of the early and intermediate term changes in a given community needed
to reach a long term goal” (Harvard Family Research Project, 2005, p. 1). The change theory
aids in creating “specific and measurable” (The Center for Theory of Change, 2013, para. 1)
goals, identifies interventions, evaluates performances, and summarizes the plan of change to
achieve the desired goal (Kritsonis, 2004, p.2).
Using the theory of change, registered nurses can develop change initiatives to promote
better patient care. One occasion when a nurse may use the change theory is when distributing
medications. Nurses pass medications frequently during their shifts. Medication errors are
common and can be detrimental for a patient. By understanding the patient safety issue, a
committee consisting of nurses can create realistic goals and interventions to decrease the
likelihood of medication errors.
Assessment of the Healthcare Environment
The healthcare industry continues to strive for safe patient care. Patient safety relies on
interventions, leadership, and teamwork from medical professionals to improve patient
outcomes. The estimated number of 400,000 patient deaths due to medical errors is unacceptable
and change needs to occur (Kuehn, B. 2014, p. 879). The duty of the healthcare industry to
cause “no harm” (Nightingale, 1863, para 1.) is essential to improving the quality of care patients
receive.
5
PREVENTING SENTINEL EVENTS
Nursing and Patient Safety
The variety of individuals involved in making healthcare safe for patients is astronomical.
However, the profession of nursing’s main responsibility is patient care and, therefore, has the
largest impact on patient safety. The Committee on the Robert Wood Johnson Foundation
Initiative on the Future of Nursing (2011) found the following:
The United States has the opportunity to transform its healthcare system to
provide seamless, affordable, quality care that is accessible to all, patient
centered, and evidence based and leads to improved health outcomes…This is
especially true for the nursing profession, the largest segment of the healthcare
work force. (p. 1)
The largest group of medical professionals involved in direct patient care is registered
nurses. From preventing patient falls, pressure ulcers, urinary tract infections, communication
errors, and medication errors, nurses are at the frontline of care and play an important role in
creating a safer environment for patients. Nurses are responsible for coordinating and integrating
“the multiple aspects of quality within the care directly provided by nursing, and across the care
delivered by others in the setting” (Hughes, 2008, p 12). Monitoring patients through continuous
assessments, discovering errors made by other professionals, and identifying potential hazards
for the patient are all part of a nurse’s daily duties to provide safe care (Hughes, 2008, p 12-13).
The registered nurse is an important professional to be involved in creating a trustworthy
environment for patients.
The Impact of Education on Patient Safety
The extensive education nursing students and registered nurses receive is a vital tool to
patient safety. The knowledge base of the nursing profession consists of “biomedical, physical,
6
PREVENTING SENTINEL EVENTS
economic, behavioral, and social sciences, ethics and philosophy” (Ballard, 2003, p.2). Nurse
education is based on evidence-based research and requires nurses to continue education to stay
current with best practices. In years past, the healthcare industry has failed to acknowledge
registered nurses as the main caregivers (Ballard, 2003, p.2). From this acknowledgement,
nurse-hiring managers began seeking baccalaureate prepared nurses in place of an associate’s
degree (Ballard, 2003, p.2). The preference of bachelor prepared nurses promoted higher
education as well as an increased knowledge of evidence based practices (Ballard, 2003, p.2).
Continuing education is also vital to the profession of nursing because patient care relies
on updated evidence based practices. Healthcare is a constantly changing environment and
registered nurses must understand all relevant changes affecting patient care. Nursing education
provides standardized care aimed to protect all patients from harm.
Nurses Scope of Practice
. Registered nurses are involved in every area of the healthcare system every hour of the
day. Nurses have the ability to think critically, identify risk factors, and intervene to improve
patient care. The registered nurse’s assessment and critical thinking skills impact the quality of
care patients receive (McNamara, 2011, p. 615). Nurses are accountable to follow policies,
procedures, the standards and ethics of nursing, and to remain competent in their practice by
meeting educational requirements throughout their career (Ballard, 2003, para. 17). The goal of
improving patient safety relies heavily on registered nurses because they are involved in every
aspect of patient care. Therefore, nurses need to step forward, speak up, become leaders, and
advocate for their patients.
7
PREVENTING SENTINEL EVENTS
Recommendations for Safety Improvements
Improving reliable and responsible care for patients is an enormous task for the
healthcare organizations. Patient care relies on providing effective, efficient care, in a timely and
equitable manner. To promote quality and safe care, requires interventions, a team committed to
change, a positive learning culture, and competent nurses. There are vast amounts of evidencebased resources available including research, National Patient Safety Goals, and accreditation
agencies geared to improve healthcare.
National Patient Safety Goals
The Joint Commission creates goals every year to improve patient safety in an effort to
improve quality care for patients. The goals are designed to focus on current problems in
healthcare and aim to improve patient safety (The Joint Commission, 2015). The Joint
Commission’s National Patient Safety Goals (NPSGs) are a major driving force for patient
safety. The Joint Commission does not have certain descriptions or concrete ways to reach the
NPSGs; however, organizations are expected to take the initiative to reach the objectives.
Committees within each healthcare facility use NPSGs to develop a plan to improve patient
outcomes. Registered nurses are an important aspect to the committee because of their clinical
background. The nurse has the potential to offer insight to other members of the team based on
personal experiences.
The team may choose to use the FMECA strategy to establish guidelines for meeting the
requirement. FMECA stands for failure modes, effect, and critical analysis. FMECA is a
systematic approach towards identifying possible failures in a system (Reams, 2011, p. 18). The
FMECA teams focus on handover communication because the organization struggles with
communicating the patients’ crucial information. The committee will critically analyze the
8
PREVENTING SENTINEL EVENTS
current process of handovers, assess the risks associated with the failures, rank the issue based on
importance, and identify actions to address the problem (Reams, 2011, p. 18). The FMECA
process can be an excellent tool to involve all members of the committee and to establish a plan
of action to address the problem.
Just Culture Approach
The development of the just culture approach can influence actions of medical
professionals involved with changing patient care. The definition of just culture is a balance
between not blaming individuals for errors and not tolerating medical errors (Barnsteiner &
Disch, 2012, p. 407-408). Prior to the just culture approach; the culture consisted of blame,
focused on who is at fault and who needs to be disciplined. The negativity related to the culture
of blame caused nurses and other professionals involved in care to hide their errors instead of
reporting them. The just culture approach promotes accountability, honesty, and mutual respect
amongst co-workers. The design of a positive culture aims to improve teamwork and
accomplish a higher standard of patient safety and quality of care (Barnsteiner & Disch, 2012, p.
407-408). Just culture focuses on flaws with procedures instead of who caused the problem.
Quality and Safety Education for Nurses
The Quality and Safety Education for Nurses (QSEN) identifies competencies nurses and
student nurses need to know. QSEN defines safety as “minimizing risk of harm to patients and
providers through both system effectiveness and individual performance” (Barnsteiner, 2011,
p.1) Incorporating the QSEN concepts into education sets standards nurses should know to create
a safer environment for patients (Barnsteiner, 2011, p.1).
QSEN competency for safety. Incorporating the QSEN competency of safety in nurse
education programs improves the “knowledge, skills, and attitudes” of future nurses to create a
9
PREVENTING SENTINEL EVENTS
safer environment for patients (Barnsteiner, 2011, p.1). A goal of the safety competency is to
“describe factors that create a culture of safety, using organizational error reporting systems for
near miss and error reporting (and) participate appropriately in analyzing errors and designing
system improvements to value vigilance and monitoring…” (Barnsteiner, 2011, fig. 2).
Work Safety
Registered nurses work long hours, have high workloads, and increasing responsibilities.
Patient care and patient safety are the nurse’s number one priority. The daily tasks of a nurse can
become tiring, especially if the departments are short staffed. All of these factors can cause
issues with patient safety; therefore, understanding the complex environment of a nursing career
is essential. Organizations have recently developed “safe zones” within medical organizations to
establish when the nurses should not be interrupted (Barnsteiner, 2011, p. 4). A “safe zone”
(Barnsteiner, 2011, p. 4) example may be red floor tiles a nurse stands in while preparing
medications. Incorporating system designs into facilities can improve patient outcomes if nurses
are accepting and accountable to the change.
Challenges in Patient Safety
Challenges in improving patient safety are endless and the role registered nurses have in
improving healthcare continues to rise. The profession of nursing is responsible for catching
medical errors before the mistake causes harm to the patient. The healthcare environment relies
heavily on nurses to implement safer healthcare; however, to achieve a higher standard of care
requires a team effort from all healthcare employees.
Changing Culture
Changing culture is one of the key factors for improving patient safety. Quality care
depends on the organization’s attitudes and accountability standards towards the healthcare
10
PREVENTING SENTINEL EVENTS
transformations implemented. The task of creating a positive approach to change can be
daunting for leaders. Creating a culture of safety is a priority within the healthcare system. The
essential elements of a culture of safety include “teamwork, patient involvement, openness to
change, and accountability. Those involved in creating this culture share the same “core values,
goals, non-punitive responses to adverse events or errors” (Barnsteiner, 2011, p. 2). Once all of
these steps fall into place, the goal of providing safe, effective, and quality care can be achieved.
To transform the organization, increased education and on-the-job training may help
motivate experienced nurses to improve healthcare. Changing the culture involves co-workers to
communicate effectively and to advocate for quality care. In addition, holding oneself and others
accountable presents its own challenge. Errors are made when steps in a system are ignored.
The facility has policies and procedures in place to prevent medical errors, and medical
professionals are responsible for following the guidelines. The extensive resources and
education serve as great tools to improve safety. Medical professionals are liable for providing a
safe, effective health system. Taking shortcuts and not following organization protocols cause
available resources to be ineffective.
Specific to Nursing
Patients are entitled to safe, quality care and nurses will always have a huge role in
promoting patient safety. Patient safety is affected by lack of appropriate staff, distractions, and
increased work hours. Recognizing and being knowledgeable about these vulnerabilities and
promoting safety will lead to a safer healthcare system.
Nursing is involved in every aspect of healthcare. Inadequate staff and a lack of nurses in
leadership roles create specific challenges to nursing. Insufficient staff leads to overworked and
exhausted nurses, which eventually may lead to medical errors. Adequate nursing staff is vital to
11
PREVENTING SENTINEL EVENTS
patient’s well-being. A nurse who feels rushed with patient care is more likely to skip steps in a
given policy or procedure. A supportive culture with registered nurses in leadership roles is
important to changing the culture. According to the Institute of Medicine (2005), there will be a
need for the number of “nurses with doctoral degrees to double by 2020” (p.111). Nurses in
leadership roles have the clinical expertise and knowledge to help create policies based on
evidence-based practices and promote a change accepting culture.
Recommendations for Quality and Safety Improvements
The Nursing Scope and Standards of Practice are guidelines all registered nurses use in
practice to provide quality patient care. The 16 Standards of Care address standards of practice
and professional performance. As a guide for patient safety, there are three standards the
profession of nursing can follow to improve quality and safety within healthcare.
Standard Eight: Education
“The registered nurse attains knowledge and competence that reflects current nursing
practice” (American Nurses Association (ANA), 2010, p. 49). Continuing education is essential
to patient safety. Current nursing practice is based on evidence for best practices.
Standard Nine: Evidence Based Practice
“The registered nurse integrates evidence and research findings into practice” (ANA,
2010, p. 51). Evidence based practice and education rely on one another. To achieve a higher
standard of care, nurses are required to utilize evidence-based skills learned from extensive
research.
Standard 10 Quality of Practice
“The registered nurse contributes to quality nursing practice” (ANA, 2010, p. 52). To
decrease medical errors, nurses are expected to advocate for a safer care system. Nurses are
12
PREVENTING SENTINEL EVENTS
13
expected to participate in committees to develop standards and policies to promote patient safety.
Involving nurses in patient safety committees can improve compliance from employees,
therefore reducing errors (ANA, 2015, p. 27). As a registered nurse, it is an ethical responsibility
to report errors according to the facility’s policy and to disclosure of the error to the patient
(ANA, 2015, p. 27).
Conclusion
Patient safety relies on communication and teamwork from all individuals within
healthcare. Once individuals are proficient at these two tasks, healthcare organizations can
effectively implement new strategies to decrease medical errors. However, to obtain competent
teamwork requires nurses in leadership positions to motivate co-workers to contribute to the
changes.
Through the development, of advanced education, promoting patient advocating, and
incorporating nurses into leadership the goal of decreasing medical errors can be attained.
Registered nurses have the ability to bring positive change and encouragement to healthcare by
utilizing the nursing scope and standards of care within the professional practice. The future of
patient safety relies on identifying areas of risk and ways to improve the current practices. The
involvement of all medical professionals can influence the culture of change to provide a high
quality and safer healthcare for the patient.
PREVENTING SENTINEL EVENTS
14
References
American Nurses Association. (2010). Nursing : Scope and standards of practice. (2nd Ed.).
Silver Spring, Md.: American Nurses Association.
Harvard Family Research Project. (2005). An introduction to theory of change. 9(2). Retrieved
April 1, 2015, from http://www.hfrp.org/evaluation/the-evaluation-exchange/issuearchive/evaluation-methodology/an-introduction-to-theory-of-change
American Nurses Association. (2015). Code of ethics for nurses with interpretive
statments. Silver Spring, Md.: American Nurses Association
Ballard, K., (2003). Patient safety: A shared responsibility. Online Journal of Issues in Nursing .
8(3), 4.
Barnsteiner, J. (2011). Teaching the culture of safety. Online Journal of Issues in Nursing,
16 (3), 5.
Barnsteiner, J., & Disch, J. (2012). A just culture for nurses and nursing students. Nursing
Clinics of North America,47(3), 407-416
Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the
Institute of Medicine. (2011).The future of nursing leading change, advancing health.
Washington, D.C.: National Academies Press.
The Center for Theory of Change. (2013). FAQs. Retrieved March 25, 2015, from
http://www.theoryofchange.org/what-is-theory-of-change/faqs/
Hughes, R., (2008). Patient safety and quality: An evidence based handbook for nurses.
Rockville M.D.: Agency for Healthcare Research and Quality.
IOM Report: Patient Safety-Achieving a New Standard for Care. (2005). Academic Emergency
Medicine, 12(10), 1011-1012.
PREVENTING SENTINEL EVENTS
James, J. (2013). A new, evidence-based estimate of patient harms associated with hospital care.
Journal of Patient Safety, 9(3), 122-8.
Kohn, L., Corrigan, J., Donaldson, M., & Ebrary, Inc. (2000). To err is human building a safer
health system. Washington, D.C.: National Academy Press.
Kritsonis, A., (2004). Comparison of change theory. International Journal of Scholarly
Academic Intellectual Diversity, 8(1), 1-7.
Kuehn, B. (2014). Patient safety still lagging: Advocates call for national patient safety
monitoring board. JAMA, 312(9), 879-80.
Mccannon, J., & Berwick, D. (2011). A new frontier in patient safety. JAMA, 305(21), 2221-2.
McNamara, S. (2011). The Future of Nursing and Patient Safety: The Nurse's Role. AORN
Journal, 93(5), 614-618.
Nightingale, F. (1863). Notes on hospitals. Longman, Green, Longman, Roberts, and Green.
Nursing Theory. (n.d). Retrieved March 20, 2015, from http://www.nursing-theory.org/theoriesand-models/nightingale-environment-theory.php
Reams, Jacqueline. (2011). Making FMEA work for you.(failure mode effects analysis). Nursing
Management, 42(5), 18.
Selanders, L., & Crane, P. (2012). The voice of Florence Nightingale on advocacy. Online
Journal of Issues in Nursing,17(1), 1.
The Joint Commission. (n.d.). Retrieved March 27, 2015, from
http://www.jointcommission.org/sentinel_event.aspx
15