Clustering 21 events with 21 patients who were having multidisciplinary care and some resulted in permanent harm or injury. 132 root causes were identified and about 53.8% were human errors while 40.2% were organizational causes. 3% of factors were identified as technical faults or patient behavioral factors. To overcome these factors, an organization aimed to improve strategic plans that could focus on the care of elder patients by providing multidisciplinary care. Improving knowledge and revision of certain protocols. Variable clustering of sentinel events and factors that contribute to using RCA can help the hospital management identify and find insight into risks and their trending patterns in an organization. RCA analysis determines the best strategies to improve safety or sentinel events in an organization that can benefit the medication administration process (Hooker AB et al., 2019).
Taking about a single sentinel event, prevention strategies to be applied that aim to improve the working environment locally and on an organizational level. Findings of RCA, hospital protocols were designed along with coordination of nurses and medical staff. Aspects that are important to patient safety and care are explained from patient admission to diagnosis, to treatment and discharge. The job description of medical specialists was updated that clearly describes the coordination of healthcare workers with interdisciplinary teams and explanation of protocols to healthcare providers and nurses in terms of patient care and medication. Application of knowledge-based approaches to improve the quality and behavior of regular examination of safety measures in a department (Hooker AB et al., 2019).
The most important strategy is how we respond to sentinel events. Since 2007, summary data shows approximately 800 yearly sentinel events have been reported in Joint Commission. Most of the sentinel events occur in medical or surgical hospital sites along will psychiatrically wards and emergency units. A good response to a sentinel event can be stabilizing the patient, reporting patient and family about the actual event, giving them support, keeping hospital leaders confident about the event, investigating the cause, RCA to find factors involved, formulating a timeline to implement action plan approved by the system (Patra and Jesus., 2021).
There are more chances of medication errors when nurses or physicians are interrupted during medicine administration to patients which affect the life of the patient. The cases of medication error due to work interruption incidents were found to be 1,152 (Getnet & Bifftu., 2017). The study was carried out in 3 hospitals in Amhara Regional State, Northwest Ethiopia. Out of 278 nurse participants chosen for the study, 222 experience work interruption more often during medication administration (Getnet & Bifftu., 2017). The results also showed that most interruptions were during the weekend when nurses do not get attention to medicine administration properly due to surrounding activities or due to enjoying the weekend charm while on duty. This needs to be improved by conducting an administrative meeting where tasks should be assigned to specific nurses under the supervision of senior staff members, so medication errors are reduced to promote patient safety/care (Getnet & Bifftu., 2017).
Preventive measures can be taken to minimize sentinel events on priority making sure about the cause of the event. Mainly 2 steps to be taken as the best strategy to respond to sentinel events which include system-based investigation of the cause of the event through root cause analysis and making a corrective action plan. Finding out what exactly happened, why it happened, and what are the latent conditions. Healthcare system design may have certain conditions about an incident that includes a provider having policies and layouts, the procedure to inherit the risk, products or resources like medical devices, peripherals (hospital infrastructure and surrounding factors, capability to prevent accidental treatments, and outdated policies.
Applying the strategy to an effective action plan that should address identification of corrective actions to control system hazards, implementation of action plans, timely completion of the action plan, applying strategy to evaluate how effective the plan is working along with strategies that sustain the change. Conductive a root cause analysis followed by a corrective action plan is the best strategy so far which is also called Sentinel Event Measure of Success (SE MOS) implemented by the Joint Commission in 2020 (Mc Gowan., 2022). The SE-MOS strategy can be beneficial with teamwor
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