Nurse Administrators’ Role in Sentinel Events

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In the contemporary world, some deaths occur due to recklessness occasioned by medical errors. Despite the efforts to guarantee quality health care and reform the current systems in the healthcare sector, sentinel events and severe errors still occur. The oath of Hippocrates requires medical experts to refrain from practices that would cause harm to patients or undermine the desired ethical considerations. This paper describes a sentinel event, identifies communication barriers that arise from this event, and explains the nurse administrators’ role in identifying and correcting issues.

Description of a sentinel event

Medical events are named as sentinel because they demand immediate response and investigation. A sentinel event entails any unforeseen occurrence that results in death, severe psychological and physical injury, or another risk thereof (Skinner, Tripp, Scouler, & Pechacek, 2015). Sentinel events are characterized by the loss of limb or motor function. The goals of a sentinel event policy seek to improve treatment and prevention measures alongside maintaining the confidence that the public has in accredited government hospitals.

Sentinel events encompass suicide that may occur in the course of patient treatment or within a span of 72 hours after discharge, patient abduction while receiving treatment, and unexpected death of a full-term infant (Garrouste-Orgeas, Flaatten, & Moreno, 2016). Additionally, incompatibilities of blood groups that cause hemolytic transfusion reactions and anticipated retention of foreign objects in the patient’s body underscore sentinel activities. This research paper identifies the death of an infant at the Aga Khan University Hospital in Karachi. The child hemorrhaged due to incubation complications leading to eventual death.

Communication barriers and healthcare practices during the sentinel event

Any adverse situation demands effective management by the health care professionals. However, various hindrances are eminent in the expression procedures relating to sentinel events (Chard & Makary, 2015). The emotional response of professionals hinders communication of errors, thus preventing appropriate care of the patients. Medical mistakes are overwhelming to all the responsible persons and especially the ones that are skewed towards sentinel events. The detrimental outcomes of a sentinel event breed tremendous emotional distress among the medical professionals (Thomson, Outram, Gilligan, & Levett-Jones, 2015). The case of infant death resulted in a feeling of shame, depression, and guilt thus triggering the failure of communication by the responsible medical staff. The disclosure of a sentinel event amounts to a sense of personal responsibility on the account of the adverse effect, and it makes the professionals feel inadequate.

The negative repercussions associated with the disclosure of sentinel events hinder effective communications of such medical errors. Due to the punitive approach associated with medical mistakes, the involved staff members feel threatened to communicate their errors or those accruing from their colleagues. Lawsuits, lose of hospital admitting privileges, revocation of license, and lose of referrals are evident consequences that hinder physicians from disclosing their mistakes originating from sentinel activities (Chard & Makary, 2015).

Nurse administrator’s role in identifying and correcting sentinel event barriers

The health care professionals assume the ethical responsibility to disclose errors and offer apologies in the case of medical errors including those associated with sentinel activities. Nurses have to abandon the myth of perfection and remove barriers that hinder communication of medical mistakes. Skinner et al. (2015) hold that nurses ought to observe the Hippocratic Oath by refraining from actions that would harm the patients. Professional standards, values, and moral principles have to be practiced by the medical professionals as part of their ethical obligations. Sentinel events demand special response. Both the organization and the professionals involved in the event have to communicate with the patient concerning a sentinel event and its consequences (Garrouste-Orgeas et al., 2016). The patient has a right to receive information on treatment alternatives and optimal courses of action.

In the sentinel event of an infant death due to incubation complications, the medical professional had the role of undertaking a root cause analysis. Causal factors arising from systems and process that bring variations in occurrences and performance are highlighted in the root cause study (Chen, Schein, & Miller, 2015). The proximate causes of the sentinel event including insufficient training of medical staff members, inadequate policies and procedures, human and equipment errors are essential during the analysis process. Deeper insights concerning the event must include investigations on whether the proper precautions were observed and the competency of the system deployed to ensure adequate staffing. Besides, the nature of communication and the extent of following policy guidelines have to undergo scrutiny. The identified causes of the sentinel event are a critical step in the root cause analysis. In the infant death context, the nurse failed to comply with the stipulated policies of the organization. The corrective actions include educating onboard staff on essential care areas and circulating flyers to every care unit to prevent the repetition of such mistakes in the future.


Sentinel events occur despite the efforts of instilling ethical obligations to the health care professions. The hindrances that accrue in the communication of sentinel events stem from the negative repercussions and emotions that come from the disclosure of information. Nurses have the role of communicating with the patients about sentinel events as well as providing advice on alternative medical options. The root cause analysis ensures the establishment of the causes, corrective actions, and learned lessons accruing from the sentinel events.


Chard, R., & Makary, M. A. (2015). Transfer-of-care communication: nursing best practices. AORN Journal, 102(4), 329-342.

Chen, T. C., Schein, O. D., & Miller, J. W. (2015). Sentinel events, serious reportable events, and root cause analysis. JAMA Ophthalmology, 133(6), 631-632.

Garrouste-Orgeas, M., Flaatten, H., & Moreno, R. (2016). Understanding medical errors and adverse events in ICU patients. Intensive Care Medicine, 42(1), 107-109.

Skinner, L., Tripp, R., Scouler, D., & Pechacek, J. (2015). Partnerships with aviation: promoting a culture of safety in health care. Creative Nursing, 21(3), 179-185.

Thomson, K., Outram, S., Gilligan, C., & Levett-Jones, T. (2015). Inter-professional experiences of recent healthcare graduates: A social psychology perspective on the barriers to effective communication, teamwork, and patient-centered care. Journal of Inter-professional Care, 29(6), 634-640.

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NursingBird. "Nurse Administrators’ Role in Sentinel Events." April 23, 2022.