The Nurse’s and Hospital’s Responsibility to Prevent the Sentinel Events from Occuring

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Nowadays, a plethora of women are choosing to give birth in hospitals. This is because hospitals are equipped the necessary equipment staff in case of an emergency. Generally joyful, the moments after the birth of a child are precious. Family members come together to visit the newborn. The parents are filled with a sense of euphoria with their new bundle of joy. However, sometimes newborns can placed in the NICU, neonatal intensive care unit. This is where infants are placed because they have underdeveloped organs, like lungs, or they are very sick. In these cases, it is extremely stressful, and families want answers as to why the illness occurs.

Occasionally, the root cause of the infant's sickness can be considered a sentinel event. Often ending in serious injury or death, a sentinel event occurs when necessary precautions are not taken by health physicians and/or nurses. This type of event is very serious because if the proper steps are taken then nothing would have happened. An example of a sentinel event is that of a newborn diagnosed with neonatal tetanus a week after birth. Uncommon in the U.S., neonatal tetanus generally occurs in third world countries where most people do not receive a tetanus vaccination. This specific type of tetanus is transmitted from mother to newborn. Neonatal tetanus is easily preventable by making sure the mother's vaccinations are up to date.

In 1995, a mother of two gave birth to her third son in a Tennessee hospital. There were no complications at birth and everything was going smoothly. A few days after his birth, the infant had muscle tension and irritability, and began to show signs of neonatal tetanus. Now seven days after his birth, the infant was diagnosed with neonatal tetanus. This was the first case of neonatal tetanus in the U.S. in six years. Questions began to quickly arise as to how this was possible. The infant's parents were immigrants from Mexico, and they grew up in rural Mexico.

This explains the possibility of tetanus; however, if the mother received the vaccine for it this still should not have occurred. The infant did make a full recovery; however, he did have to spend two months in the hospital. Researchers asked physicians and nurses in Tennessee if they acquired the mother's vaccination chart during her prenatal care. According to The Pediatric Infectious Disease Journal, “The survey of obstetrical practices [in Tennessee) revealed that 61 (59%) of 103 respondents asked about the patient's vaccination status during prenatal care. However, of all only 14 (14%) confirmed that they specifically asked them about prior tetanus vaccinations. Tetanus toxoid was available in 47% of offices on the day of the survey." In other words, the mother could have easily gone to a clinic or doctor's office where they do not acquire vaccination records.

Nurses are the last line to the patient. It is their responsibility to make sure nothing has been looked over. In this infant's case, many people, including nurses, looked over an important step. If the necessary precautions are not taken, a sentinel event like this one can occur. This is quite unfortunate because these events are usually easy to prevent. For example, if the mother received the necessary prenatal care the infant would not have been sick. However, something as simple as checking vaccination records caused a long recovery for this infant.

As a nurse, I can prevent sentinel event from occurring by making sure I take to necessary precautions. Now knowing that checking the vaccination record of pregnant women is pertinent to ensure a healthy baby, I can make sure that all the vaccines and boosters are up to date, and if not, I can administer them. In order to do this, I would need the approval of a physician, but I can make sure that they know to check whether or not the vaccines are up to date. As a nurse, I can be an extra pair of eyes for the physician, and I can double check to make sure nothing gets over looked. No one should have to experience some of the serious aftermath of a sentinel event because they are generally goof ups that hospital staff make. People rely on nurses to take care of them, so it is a devastating breach of trust when a nurse makes a harmful or even deadly mistake.

As I am not yet in nursing school, I have not learned the necessary steps that need to be obtained. However, once I do I will make sure to study them in order to have them down pact. It is crucial to take these steps in an orderly and timely fashion. I will begin with the basics. For example, washing or sanitizing my hands before I come in contact with a different patient. I can practice safe methods by following the dress code. This is not only to look professional, but to also ensure a sanitary environment. For example, nail polish may look pretty and clean; however, if the nail polish chips, bacteria can grow in the areas that are not well scrubbed. If this happens, I can spread bacteria to patients that already have a weak immune system. Another precaution I will take is to make sure I read the label before administering any drug to a patient. If I were to assume that the drug I grabbed is the correct one, I could be mistaken and then I could hurt the patient. Not reading a label could result in the wrong dosage or even the wrong drug. More often than not, a patient's body is already weak, and giving them the wrong dosage or drug can be detrimental to their health or even fatal. There are many other precautions that I will need to make sure I follow as a nurse, but these are the basic ones that can still greatly impact the well being of a patient.

Hospitals are constantly improving, whether that be with equipment, medications, or treatments. The regulations and rules may sometimes be overlooked. A hospital may have an intricate set of guidelines that they expect all hospital staff to uphold. However, if the staff members do not understand them, the guidelines may not be as useful. As best stated in JONA's Healthcare Law, Ethics, and Regulation, "Clarity in an organization's mission, vision, and values is key to effective management in today's increasingly complex healthcare work environment. To clearly articulate mission, vision, and values, employees must experience consistency between what is espoused and what is lived. Although most healthcare organizations have written documents that advocate caring missions, often the work environment fails to translate caring into the professional practice setting. This situation creates an ethical dilemma that interferes with organizational commitment and impedes organizational success."

This is basically saying that hospitals need to clarify there rules and regulations because some health care workers do not understand or know them. That is probably one of the major changes hospitals should do. Already having regulations to insure safe and quality practices, hospitals need to make sure that their employees fully understand them. More and more sentinel events can have prevented if hospitals did this. Another measure that should be taken is that nurses need to understand that they need properly fulfill all of the regulations because they are the last line to the patient. There generally is no one there to constantly double-check and make sure everything is done correctly for a nurse.

As a soon to be nurse, I fully comprehend that my job deals with the matter of life or death. In order to avoid sentinel events, I will ensure that I have complied with the hospitals rules and regulations. Also, it is pertinent I consistently obey the necessary precautions before I help a patient. Situations, like the infants, are very unfortunate. No should have to admit their newborn into a hospital for two months because someone did their job incorrectly. Hospitals should also take the necessary time to make sure their staff understands their regulations. This can be as easy as an occasional staff meeting within the different units. Something as simple as a staff meeting can prevent horrific events in the long run.

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The Nurse's and Hospital's Responsibility to Prevent the Sentinel Events from Occuring. (2022, Sep 30). Retrieved July 17, 2024 , from

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