Sentinel Events in Nursing Practice

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In nursing and healthcare settings, sentinel events are described as significant unexpected negative outcomes that point to potential flaws or discrepancies in care provision (Connelly, 2012). These events are caused by factors such as medical errors, incapacity or unwillingness to follow health practices, poor communication, and weak or unclear organizational structures and processes (Tzeng, Yin, & Schneider, 2013).This paper uses a case to not only identify barriers in communication and healthcare practices that precede a sentinel event, but also to explain the nursing administrator’s role in identifying and correcting the barriers.

Event Description

The sentinel event revolves around a young female patient who contracted MRSA at the post-op unit, where she was being observed after a successful appendectomy. The patient was exposed to MRSA through a nurse who came into contact with the pathogens due to failure to follow hospital protocols on gloves use and hand washing. The MRSA pathogens had been transferred to the counter by a visitor who was taking care of her father in the post-op unit. As demonstrated in the case, the father had a surgical wound that was infected with MRSA. Earlier, the visitor had observed a resident professional assessing her father twice without following proper hand washing techniques but failed to report this incident to the relevant authorities. It is also reported how the family member took her young child to the hospital to visit her father despite the boy being sick with flu. The young female patient ultimately died of MRSA even though she had been admitted to the unit due to the appendectomy.

Barriers in Communication and Healthcare Practices

In communication, it is clear that the family member who was visiting her father in the post-op unit failed to report her observations on poor infection control measures and noncompliance with hospital protocols even after having the knowledge that the surgical resident failed to follow proper hand washing techniques. Also, a nurse who had observed the family member exit the patient’s room with gloves failed to communicate that it was against the unit’s infection prevention protocols to move around with unclean gloves. This barrier in communication could be as a result of factors such as nurse workload demands, insufficient time, lack of clear policies on how to raise complaints and concerns, ignorance, and attitudinal problems (Hemsley, Balandin, & Worrall, 2012).

In healthcare practices, it is evident that the unit did not follow proper infection prevention strategies particularly with regard to hand washing and use of gloves. This barrier led to the transfer of MRSA from the male patient to the female patient through poor hand washing habits. Additionally, while most hospitals do not allow young children to visit post-op wards due the high probability of getting hospital infections such as MRSA (Chowers, Carmeli, Shitrit, Eihayany, & Geffen, 2015), it is clear that this practice was not followed in this particular case as the family member was allowed to visit her father with a young boy who was sick with flu. Available literature underscores the importance of proper hand hygiene in preventing the transfer of nosocomial infections (Garus-Pakowska, Sobala, & Szatko, 2013). Indeed, health professionals and visitors to the hospital are required to wash their hands or use hygienic hand disinfection after coming into contact with patients regardless of whether gloves are used or not.

Nursing Administrator’s Role

The Nursing administrator can use the root cause analysis to identify and correct the barriers that caused the sentinel event. The root cause analysis is described as “a systematic process used to address problems or non-conformance to identify the source of the problem” (Connelly, 2012, p. 316). As a leader, it is the role of the nurse administrator to develop strategies and approaches that will break down the barriers to identify their root causes. For example, the administrator can use her position to solicit for funds to be used in undertaking a comprehensive survey on service provision and quality care indicators within the unit. Such a survey is likely to identify the proximal root causes of the identified barriers and help in determining if the root causes are related to human error or institutional factors such as poor implementation of procedures and policies. In the case, it is evident that both human error and institutional factors are to blame.

After identifying the root causes, it should be the administrator’s role to lead in the development and implementation of policies and strategies that will reinforce effective communication and compliance with proper infection prevention techniques at the unit level. Here, the administrator can arrange for nurse education and awareness creation on the need to maintain proper hand washing habits in the unit. It is also possible to conduct an organizational assessment of nurses engaged in care provision and coordination to identify the training and competencies that need to be provided to nurses to improve hygiene standards and trigger effective communication across the care continuum (Shulman, 2015). Additionally, it is the role of the nurse administrator to provide patients and families with a point of contact for use in reporting observed lapses in hospital protocols. Lastly, the manager should lead efforts aimed at strategizing and optimizing information sharing opportunities by putting posters on hand hygiene and gloves disposal at strategic locations and mounting a complaints box at the entry of the ward (Shulman, 2015).


Drawing from this discussion and analysis, it is evident that sentinel events can serve as an important tool for reinforcing the healthcare system and averting future undesirable consequences if concerted efforts are made to analyze and address their root causes.


Chowers, M., Carmeli, Y., Shitrit, P., Eihayany, A., & Geffen, K. (2015). Cost analysis of an intervention to prevent methicilin-resistant staphylococcus auereus (MRSA) transmission. PLoS ONE, 10(9), 109.

Connelly, L.M. (2012). Root cause analysis. MEDSURG Nursing, 21(5), 313-316.

Garus-Pakowska, A., Sobala, W., & Szatko, F. (2013). Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II. International Journal of Occupational Medicine and Environmental Health, 26(2), 257-264.

Hemsley, B., Balandin, S., & Worrall, L. (2012). Nursing the patient with complex communication needs: Time as a barrier and a facilitator to successful communication in hospital. Journal of Advanced Nursing, 68(1), 116-126.

Shulman, K.M. (2015). Joint statement: The role of the nurse leader in care coordination and transition management across the healthcare continuum. Nursing Economic$, 33(5), 281-282.

Tzeng, H.M., Yin, C.Y., & Schneider, T.E. (2013). Medication error-related issues in nursing practice. MEDSURG Nursing, 22(1), 13-50.

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NursingBird. "Sentinel Events in Nursing Practice." April 24, 2022.