Sentinel Event Analysis Learning Activity

Submitter Information

Author: Gail Armstrong, ND, RN
Title: Assistant Professor
Institution: University of Colorado Denver College of Nursing
Email: gail.armstrong@ucdenver.edu

Competency Category(s)
Safety

Learner Level(s)
Pre-Licensure ADN/Diploma, Pre-Licensure BSN

Learner Setting(s)
Classroom

Strategy Type
Case Studies

Learning Objectives

  • Examine human factors and other basic safety design principles as well as commonly used unsafe practices.
  • Demonstrate effective use of technology and standardized practices that support safety and quality.
  • Value the contributions of standardization/reliability to safety.
  • Appreciate the cognitive and physical limits of human performance.
  • Value own role in preventing errors
  • Describe processes used in understanding causes of error allocation of responsibility and accountability (such as root cause analysis and failure mode effects analysis).
  • Discuss potential and actual impact of national patient safety resources, initiatives, and regulations.
  • Use national patient safety resources for own professional development and to focus attention on safety in care settings.
  • Value relationship between national safety campaigns and implementation in local practices and practice settings.

Strategy Overview

This learning activity explores various facets of sentinel events and national patient safety goals. This activity can be used in a junior or senior level Med/Surg class, or in an OB class, because the sentinel event analysis focuses on an event with a healthy newborn.
Prior to the class, I ask the students to complete the following homework:
1) Please go to the website for The Joint Commission (www.jointcommission.org) and use the “Sentinel Event” link at the top of the homepage to read all the background information on sentinel events. Use the “Patient Safety” link and read the provided information on National Patient Safety Goals. Download the “2009 NPSG Powerpoint Presentation” and review it. Take notes on the NPSG that are new for 2009.
2) Please read the following two articles:
Berntsen, KJ. (2004). How far has health care come since “to err is human”? Exploring the use of medical error data. Journal of Nursing Care Quality. 19(1): 5-7.
Smetzer, JL. (1998). Lesson from Colorado: beyond blaming individuals. Nursing Management. 29(6): 49-51.
3) Be sure to review levels of research evidence as outlined in Chapter One of: Ackley, B.J., Ladwig, G.B., Swan, B.A., & Tucker, S.J. (2008). Evidence based nursing care guidelines. St. Louis: Mosby
During class, we review what the students learned about sentinel events and NPSG from The Joint Commission’s website. I focus the discussion on the connection between sentinel event reporting and the evolution of new NPSG each year. We also spend time on the NPSG for the coming year.
The Berntsen article is useful in recounting recent history of systems’ approaches to addressing patient safety issues. Although new approaches have emerged in patient safety since this 2004 article, Berntsen’s article is helpful in providing students a sense of how systems change, and some of the barriers in the years immediately after “To Err Is Human.”
We also review the Smetzer article together in class. This article outlines a sentinel event from Colorado that resulted in the death of a newborn. This 1996 case resulted in three nurses being indicted on charges of negligent homicide. The author of this article used information prepared for the trial to identify over 50 different failures in the system that allowed this error to develop, remain undetected and ultimately, reach the infant. As one of the article’s most poignant points, the author states, “Had even one not occurred, the chain of mistakes would have been broken and the infant would not have been harmed.” (p48).
After the class discussion, I ask the students to complete the following paper:
In her article, Lessons from Colorado: Beyond Blaming Individuals, Judy Smetzer identifies 14 system failures that were present in the case newborn Miguel. These 14 system failures are:
  • Incomplete clinical information
  • The language barrier
  • Inconsistent procedure for communicating prenatal care
  • Staff inexperience and poor documentation
  • Nonstandard method of writing the drug order
  • Insufficient drug information
  • Lack of a unit dose system
  • Insufficient information on infant injections
  • Inconsistent independent double check system
  • No staff education before dispensing nonforumlary drugs
  • Insufficient drug information and inadequate drug references
  • Unclear definition of nonphysician prescriptive authority
  • Unclear manufacturer labeling
  • Conflicting information on IV use of milky white substances
Choose two system failures from Smetzer’s list of 14 and complete the following assignment:
For each system failure that you choose, write a paragraph explaining how the system failure contributed to the sentinel event of the article. What kind of precautions would be needed to avoid a repetition of this particular system failure? From which discipline might this precaution emerge (e.g. nursing, pharmacy, medicine, nursing administration, hospital administration)?
For each of the system failures that you have chosen, find the most recent piece of evidence, with the strongest level of research evidence (I – VII) that demonstrates either research being done in this area, or new recommendations to address this particular system failure. If you cannot find any evidence based practice, or research in this area, see if you can find a national initiative (e.g. National Patient Safety Goal, initiative from 5 Million Lives Campaign, initiative from The Leapfrog Group, IOM recommendation) that addresses this system failure. Provide a summary of the article or initiative, and if appropriate, attach a copy of the article to your paper.

Submitted Materials

Additional Materials

Evaluation Description

The Smetzer article is an extremely powerful exploration of a sentinel event for junior nursing students’ reading. They are consistently captivated by the accessability of the 14 system failures outlined in Smetzer’s very concise article.
I have often not graded this assignment, but use it for small group discussion, because the article is often a turning point for the students in understanding how errors are not about blaming individuals but about addressing systems.