Question

Please provide proper citation with page numbers of the material you are referencing in your homework paper. Homework assignment should be 1-2 pages, not including reference page, double-spaced.

Review an article related to a sentinel perioperative event.

Be sure to summarize the article. Include the following:

What is a sentinel event?

Give background information on the patient (i.e. age, past medical history, admitting diagnosis).

Discuss the cause of the sentinel event, if it resulted in any complications (i.e. injury, trauma, death).

Discuss preventable measures related to this event (i.e. raise side rails, review of 5 rights of medication administration, etc.).

What did you learn from the article?

Answer 1

Review

Case

A operation was  performed for the correction of fracture of neck of the femur of a 54 year old male patient with complaints of unbearable pain ,swelling and history of falling from stair.  After the incision and desection of leg they appreciated that there no such fracture present. They took x ray of other leg then do the procedure for the correction.  

sentinel event

Sentinel events are unexpected event that result in patient's death or serious physical or psychological injury.

Example of most commonly occurring sentinel event include unintended retention of foreign injection,falls and performing procedures on the wrong patient. Serious injury specifically loss of limbs or body part

sentinel event in this case that surgery on the wrong leg. It may happened during the preoperative Medical procedure  from assistance . Might be due to communication problem

Most common root causes of sentinel events

• Human factors (most common cause in perioperative sentinel events)
• Assessment
• Information management
• Operative care
• Medication use
• Communication
• Leadership
• Physical environment
• Care planning

In this case the patient ,this event causes injury to the patient

complications

• injury(physical or psychological)
• Trauma
• Death

Events -all of the following events can be considered as sentinel events even if the outcome was not death or major permanent loss of function .

• Infant abduction or discharge to wrong family
• Unexpected death of full term infant
• Surgery on the wrong individual or wrong body part
• Instrument or objects left in patient after surgery or another procedures
• Rape in acute care settings
• Hemolytic transfusion reaction due to blood group incompetence
• Radiation therapy to wrong body region

prevention

wrong patient,wrong site , wrong procedure events and unintended retention of foreign body has been identified as top repeated sentinel events

●Should note the 5 rights of medication administration (5R) during all Medical procedure. ●

1. Right patient
2. Right drug
3. Right dose
4. Right route
5. Right time

•prevent and reduce retained surgical items events

•prevent and reduce wrong patient,wrong site,wrong procedure events