Sentinel Event Final
Sentinel Event Final
Sentinel Event Final
Shaylee Hawn
November 8, 2022
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In the year of 2021 alone, there were 710 sentinel events related to patient falls (The Joint
Commission, 2022). Sentinel events are accidents or near-misses that harm the patient in any
way or cause death (The Joint Commission, 2022). One specific sentinel event happened when a
patient at a nursing home died as a result of complications from an unwitnessed fall. A root cause
analysis of the event revealed that the facility was understaffed and failed to implement several
safety precautions, such as including a fall prevention plan, reporting known falls, and frequently
monitoring patients who have a high risk of falling. A quality improvement plan was developed
to help prevent falls from happening in the future which includes scanning patient barcodes,
evaluation of the plan, using Kirkpatrick’s Evaluation Model, will maintain that the steps taken
Sentinel Events
The Joint Commission describes sentinel events as patient safety events that cause the
patient temporary or permanent injury and in severe cases, death (The Joint Commission, 2022).
The Joint Commission is a not-for-profit agency that advocates for patient safety and aims to
ensure quality healthcare by evaluating and accrediting healthcare organizations and providing
feedback to improve patient care (Wadhwa & Huynh, 2022). Therefore, when a patient suffers
temporary or permanent damage or dies in a medical facility, an investigation into the event can
help understand why it happened as well as prevent it from ever happening again. Sentinel events
frequently reviewed by The Joint Commission include falls, unintended retention of a foreign
object, wrong surgery, suicide, and delay in treatment. The number of reported sentinel events in
2021 ranked an all-time high of 1,197 events. Sentinel events indicate that there is a lack of
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safety protocols and procedures to prevent that event from happening, therefore, immediate
research and response is required to prevent the same event from happening again (The Joint
Commission, 2022).
When a sentinel event occurs, the organization is strongly encouraged, but most are not
required to report the event to The Joint Commission (The Joint Commission, 2022). According
to the Agency for Healthcare Research and Quality (AHRQ), only 11 states have mandated that
medical facilities report sentinel events while 16 states mandate reporting of serious adverse
events (AHRQ, 2019). When The Joint Commission is notified of a sentinel event, the
plan within 45 business days of the event (The Joint Commission, 2022). This analysis and
action plan should be submitted to The Joint Commission, who will review and evaluate the
material. When The Joint Commission determines that the analysis and action plan are
acceptable and will effectively reduce the risk of further events, a follow up activity will be
assigned to the organization to promote safety and prevent the possibility of reoccurrence. The
Joint Commission evaluates the organization’s response to the event using data collected through
the sentinel event measure of success process. This process evaluates the effectiveness of the
planned corrective actions so that the organization may get approval or additional feedback and
In April 2018, an 84-year-old man, Mr. King endured a stroke and was admitted to
Cathedral Village, a nursing care facility in Philadelphia, for rehabilitation on April 9, 2018
(Jean, 2022). Mr. King stayed at the rehabilitation facility for three days until he was transferred
to Cathedral Village’s senior living facility on April 12th. At approximately 11:30 p.m. on the
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same day, a staff member found Mr. King on the floor in his room after an unwitnessed fall. Mr.
King was assisted back into his bed before the nurse left him to sleep for the night. When a nurse
went to check on Mr. King the next morning on April 13, 2018, at 7:00 a.m., King was
discovered deceased in his wheelchair in the lobby of the facility. Mr. King’s autopsy revealed
that he had sustained a subdural hematoma as a result of his fall. After Mr. King’s stroke and
then an unwitnessed fall, he required routine neurological checks to assess for any deficits in his
neurological status. Summer, the Licensed Practical Nurse (LPN) responsible for this patient,
documented that she completed eight neurological checks on this patient after his fall. However,
upon further investigation, video footage at the care facility revealed that she had not checked on
or performed any neurological assessments on Mr. King between the time of his fall and the time
he died. If Nurse Summer had completed these neurological checks, she could have identified
Mr. King’s deteriorating status so that he could be transferred to a hospital for more acute care
and possibly saved his life. It is important to note that Mr. King’s fatal fall was not his first, in
fact, it was his fifth during his four days at Cathedral Village. Additionally, while Nurse Summer
was responsible for caring for Mr. King at the time of his death, she was also responsible for
caring for 36 other patients at the same time (Jean, April 21, 2022).
A fishbone diagram analyzes and portrays all the factors that ultimately made this
sentinel event possible (see Appendix A). Environment, equipment, leadership, communication,
people, and procedures are all components of the fishbone. Another useful tool is the strengths,
weaknesses, opportunities, and threats (SWOT) analysis (see Appendix B). A SWOT chart can
help analyze what went well during the event as well as what needs to be improved. Both tools
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were created to get a better picture of this specific event and to find ways to prevent it from
reoccurring.
For the first category of the fishbone regarding environment, Mr. King’s fall happened at
a facility that was severely understaffed with unsafe patient ratios averaged between 30-60
patients per nurse. Nurse Summer had 37 patients to care for during her shift, including patients
with dementia, behavioral issues, psychiatric illnesses, and therapy patients like Mr. King. This
was a common ratio for nurses at Cathedral Village at the time even though staff was aware that
this was an overwhelming and dangerous workload, which makes this a problem in the
leadership category. Leadership positions at Cathedral Village also failed to provide adequate
supervision and interventions to prevent falls for patients with a fall risk. Under the equipment
category, the absence of a cameras in patient rooms and a central monitor at the nurse’s desk
required nurses to walk to each patient’s room to simply check the patient’s vitals. This is why
Mr. King was not discovered until the next morning. For the category regarding communication,
poor staff communication meant that the frequency of Mr. King’s falls was not made apparent to
the senior living facility when he was transferred from the rehabilitation facility on the same
premises. When Mr. King was found on the floor after his last fall, it was not reported to his
primary nurse or supervisors on that shift. For the category regarding people, Nurse Summer
could have also underestimated the severity of Mr. King’s status or lack the knowledge to know
how important neurological checks are, especially for a stroke patient who had an unwitnessed
fall. Mr. King’s deteriorating neurological status could have been identified earlier had the nurse
simply walked into his room to check on him or asked someone else to. For the category
regarding procedure, based on Mr. King’s neurological status, he should have been placed in a
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1:1 ratio instead of 37:1. Additionally, a fall prevention plan was not put in place or carried out
For the strengths category of the SWOT analyses, a thorough investigation was
completed on this incident to determine the contributing factors. Additionally, the Nurse Summer
knew that she was supposed to chart the neurological assessments because she falsely
documented them. Weaknesses of this event include the facility being severely short staffed with
unsafe ratios, Mr. King was not on a fall prevention plan, and neurological assessments were not
performed. Mr. King was also not routinely assessed, and his fatal fall was not reported to the
primary nurse and supervisors. The nurse was forced to falsify charting due to a lack of time and
neurological checks, encouraging communication between nurses and leadership, and providing
quick methods to monitor a patient’s status. Additionally, other opportunities include adding all
risks to care plans, developing a fall reporting system, increasing communication between all
facilities, and requiring patient scans before neurological checks. Threats include continued short
staffing, lack of safety protocols, and shortcuts of preventative measures (see Appendix B).
Understaffing with unsafe ratios, lack of time to frequently monitor patients, and failed
assessments ultimately led to the death of Mr. King. To prevent this type of event from
happening again, video observation systems should be put in place for fall risk patients, safe
nurse-patient ratios should be mandated by law in every state, and time-sensitive, high-acuity
assessments should require patient barcode scanning. To implement this quality improvement
plan in a timeframe of 7 years, leadership positions, nurses, physicians, social workers, local
politicians, patients, and local and state governments must be involved. Nurses, physicians, and
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social workers need to be involved because this plan will affect their workflow and how they
assess and care for patients. Leadership positions such as Chief Executive Officers of nursing
homes and hospitals will need to authorize and initiate this plan as well as accommodate for the
new requirements. Local politicians, as well as local and state governments need to be involved
to draft laws and help push through the legislation required to implement safe staffing. The goal
of the quality improvement plan is to decrease patient deaths related to and the total number of
Ratio Laws
The most important intervention to prevent this event from reoccurring is nurse-patient
ratio laws in each state. Currently, California is the only state that legally requires set nurse-to-
patient ratios in each hospital unit (Davidson, 2022). Nine other states, including Connecticut,
Nevada, Ohio, Texas, Minnesota, Illinois, New York, Oregon, and Washington have hospital-
based staffing committees that review the hospitals needs and the number of nurses to determine
nurse-to-patient ratios (Davidson, 2022). Five of these states require hospitals to report hospital
staffing to the state (Davidson, 2022). This means that nurses are often left with unsafe ratios
when there are large volumes of patients because the hospital has no legally required nurse-to-
patient ratios. A positive response is expected from patients, nurses, physicians, and other
hospital staff as ratio laws create a safer environment for patients and allow for more thorough
care. While there may be pushback from lawmakers and the CEO’s and governing boards of
medical facilities due to the amount of time to pass ratio laws and the financial requirements of
staffing more nurses, this change is necessary to ensure patient safety and prevent future sentinel
events. A research study performed in 11 different hospitals demonstrated that the number of
staffed nurses can accurately predict patient falls: increased staffing results in fewer patient falls
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(Kalisch et al., 2012). Additionally, fall rates decrease when routine nursing care is completed
(Kalisch et al., 2012). Therefore, mandating adequate staffing can prevent falls from happening
and can provide nurses with enough time to complete required care on each of their patients
Barcode medication administration (BCMA) on the electronic medical record (EMR) has
been proven to reduce medication administration errors by 80% (Bonkowski et al., 2013).
Therefore, barcode scanning can be used to prevent errors in neurological checks, like wrong
time, wrong patient, or failure to complete. Requiring nurses to scan the patients barcode in order
to electronically document and confirm that the neurological assessment was performed correctly
verifies that the nurse assessed the patient due to the importance of these assessments. Most
hospital staff and patients will welcome this component of the quality improvement plan while
nurse may push back due to the additional measure added on their task load. However, scanning
the patient’s barcode is an extremely quick process that should only add seconds to the time it
takes to complete a neurological assessment. Additionally, this can verify that the assessment
was done at the correct time due to the time-sensitivity of these assessments. This adaption into
EMR’s can easily be introduced into hospitals as well as nursing homes to decrease the overall
As about 63% of injury-related falls in older adults result in death, preventing falls is of
imminent importance (James & Carter-Templeton, 2021). This is especially true in rehabilitation
centers and nursing homes, where many patients experience altered mental statuses, are
recovering from recent injury or trauma, and are sometimes on multiple medications that affect
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gait. Additionally, 73% of stroke patients, like Mr. King, fall within the first year after a stroke.
When analyzing the benefits of installing centralized video observation in rooms of 34 high fall-
risk patients, fall rate decreased by 100% over the 6-week period. Incorporating centralized
video observation (CVO) into fall prevention plans is a way to monitor patients at all times as
well as providing an effective alternative to patient sitters. A bonus benefit of video observation
is decreased money spent on sitters as well as potential falls, with the estimated saving of this
specific study being $88000 (James & Carter-Templeton, 2021). Positive feedback is expected
from nurses and other hospital staff including leadership positions because this is an easy and
quick way to assess patients and increases patient safety while minimizing unfortunate events.
However, mixed feedback is expected from patients and their families as some people feel that
cameras are an invasion of privacy. These feelings can be addressed by educating the patient and
their family on increased safety created with cameras and refraining from using cameras in
patient rooms who strongly object to it. CVO can be installed in the rooms of each patient who is
suspected to or has a history of high risk for falls as way to quickly assess a patient’s status
rather than relying on nurses to constantly check on a patient or hiring sitters for every patient
with a fall risk. This requires cameras to be installed in patient rooms as well as a central desk
with monitors where a monitor technician can watch video surveillance from multiple rooms at
Change Strategy
Dr. Kotter’s change model is a successful strategy to implement this quality improvement
plan. The first step is to create a sense of urgency (Kotter, n.d.). A sense of urgency can be
created by educating the public about the statistics and severity of falls in hospitals and
outpatient settings. As the numbers of falls continues to dominate the list of the most common
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sentinel events, this issue is not one that should be left undiscussed (The Joint Commission,
2022). Politicians and local and state governments need to be informed of the unsafe nurse-to-
patient ratios until change is enacted in each of the 49 states that does not have a ratio law. The
second step is to create a volunteer network of individuals committed to solving the problem at
hand (Kotter, n.d.). This can be by educating and encouraging nursing staff, physicians, hospital
boards, politicians, and local and state governments about their role in advocating for and
maintaining patient safety. The third step is to form a strategic vision to demonstrate how the
future will be improved with the implementation of this plan (Kotter, n.d.). By informing nursing
standards organizations, hospital CEO’s, medical staff, and government officials how adopting
patient barcode scanning for neurological assessments, implementing safe staffing ratios, and
incorporating CVO into medical facilities can save patient lives, the created plan of action can be
put into motion in every hospital and outpatient setting. The fourth step is to enlist a volunteer
army because wide-scale change happens only when large numbers of people are working
together to solve the issue (Kotter, n.d.). Creating a large group of dedicated people can be
accomplished by having sign up campaigns at medical facilities across the country as well as
recruiting the public through social media campaigns. This will recruit a wide variety of
volunteers who will advocate for safe staffing and fall prevention plan updates in their state as
well as encouraging additional peers to become part of the campaign. The fifth step is to enable
Barriers can include negative feelings or resistance towards the quality improvement plan
and medical facilities’ unwillingness to incorporate these changes. The best way to remove these
barriers is continued education about the increased patient safety that the plan will bring forth
and legally enforcing ratio laws. Additionally, advocating for nursing ratios can encourage more
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students to go into the nursing profession or more ex-nurses to return to nursing, which could
help decrease staffing problems that hospitals currently face. The sixth step is to generate short
term wins (Kotter, n.d.). This can include tracking progress of the number of volunteers
advocating for this quality improvement plan as well as recognizing facilities who are quick to
implement CVO and patient barcode scanning for neurological assessments. The seventh and
eighth steps are to continue accelerating in the plan and to institute change by evaluating systems
to reinforce the new behaviors (Kotter, n.d.). This can be done by keeping track of falls and
patient outcomes at facilities that have implemented all of these changes and evaluating whether
the improvement plan has been beneficial or not and revising as needed.
Implementation
This plan will be implemented over a span of 7 years with 2030 being the cutoff date for
the three interventions to be in place at every medical facility in the country. The first steps
include educating and encouraging nursing staff, physicians, hospital boards, politicians, and
local and state governments about their role in advocating for and maintaining patient safety.
Education and advocacy will take place over the first two years to build large fall prevention
advocacy groups to meet with and influence hospital boards, national nursing organizations, and
government officials to get everyone on the same page. Educational meetings will be offered at
every major hospital in each state with the requirement that charge nurses and supervising
hospital and nursing home staff have to attend one meeting so that they can bring the information
back to their peers. Patient barcode scanning for neurological assessments and CVO are
interventions that can be nationally implemented into fall prevention plans within 3 years.
Legally enforcing ratio laws and implementing change in the national standard for fall
prevention is a lengthy process that will be in the process of acceptance during years 3-7 and
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finalized by 2030. While pushback is to be expected along the way, this quality improvement
plan was developed solely for the purpose of patient safety and had been given a generous
Kirkpatrick’s Evaluation Model will be used to determine whether or not the quality
improvement plan produced the expected results of decreased patient deaths related to falls.
Level 1 determines the participants response toward the plan (Kirkpatrick Partners, 2022). This
will consist of a 5-star rating system used by nursing and medical staff after the 2 years of
education to understand how they feel about the plan affecting their workflow. The responses
will be analyzed to determine if there is any additional education or tools that should be provided
in order to ease the implementation of the quality improvement plan. Level 2 consists of
(Kirkpatrick Partners, 2022). A 10-question retention quiz about fall prevention will be required
for each person responsible for patient care, specifically nurses, to take after being presented
with the information with a passing score of 80% required. This will also be administered after
the 2 years of education. Level 3 determines if the information had been applied in practice
(Kirkpatrick Partners, 2022). This will be done by facilities continuing to monitor and report
staffing ratios as well as the number of patient falls and barcode scanning rates for neurological
assessments. Level 4 analyzes the benefits implementing the plan has provided (Kirkpatrick
Partners, 2022). The number of patient falls reported to The Joint Commission will be analyzed
and compared to past numbers which will be published online for each medical facility to
review. Hospital specific results will be sent to each facility so that they can determine if they are
assessments will be conducted in 2032 by analyzing the scanning rates at each facility and
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addressing any concerns. Staffing levels of each medical facility will also be analyzed in 2032 to
confirm that ratio laws are being followed. Staffing ratios, patient deaths related to falls, and fall
rates will be required to be reported to The Joint Commission so that results can be published
Creating a safe patient outcome is one of the biggest priorities for healthcare personnel.
Mr. King is one of the many patients who have died after sustaining an unwitnessed fall in a
medical facility that was severely understaffed. With the root cause analysis showing multiple
safeguards being neglected, including implementing a fall prevention plan for a patient with a
history of falls, performing neurological assessments after a fall, and reporting and documenting
falls, a quality improvement plan consisting of enforced ratio laws, barcode scanning for
neurological assessments, and centralized video observation has the possibility of decreasing the
number of patients falls significantly, if not completely. Additionally, the evaluation process
using Kirkpatrick’s Evaluation Model will provide important feedback that can be used to
improve the quality improvement plan to make it even more efficient. Implementing this quality
improvement plan has the ability to prevent patient deaths related to falls and prevent patient
falls altogether.
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References
https://psnet.ahrq.gov/primer/never-events#:~:text=Sentinel%20events%20are
%20defined%20as,analysis%20after%20a%20sentinel%20event.
Bonkowski, J., Carnes, C., Melucci, J., Mirtallo, J., Prier, B., Reichert, E., Moffatt-Bruce, S., &
https://doi.org/10.1111/acem.12189
Davidson, A. (2022). Nurse-to-patient staffing ratio laws and regulations by state. Nurse
Journal.
https://nursejournal.org/articles/nurse-to-patient-staffing-ratio-laws-by-state/
Davis, J. E. & Carter-Templeton, H. (2021). Augmenting an inpatient fall program with video
https://doi.org/10.1097/NCQ.0000000000000486
Jean, J. Y. (April 21, 2022). How short-staffing and unsafe patient ratios led to the
https://nursejournal.org/articles/short-staffing-unsafe-patient-ratios-mcmaster-christiann-
gainey/#:~:text=It%20is%20reported%20Gainey%20was,the%20morning%20of%20his
%20passing
Kalisch, B. J., Tschannen, D., & Lee, K.H. (2012). Missed nursing care, staffing, and patient
https://doi.org/10.1097/NCQ.0b013e318225aa23.
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kirkpatrick-model/
https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/
Wadhwa, R. & Huynh, A. P. (2022). The Joint Commission. National Center for Biotechnology
Information. https://www.ncbi.nlm.nih.gov/books/NBK557846/
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Appendix A
Appendix B
5 Introduction
interesting first sentence, no use of "this author" or "in this
paper" Then include the major points from sentinel events in
general, from your specific event, the root cause, the QI plan,
the evaluation and dissemination.
10 Sentinel Events in General