A Sentinel Event Related To Nurse Fatigue Nursing Essay

12 hour shifts, extended work periods, voluntary and mandatory overtime, and increased workloads are all factors that dangerously contribute to nurse fatigue, which includes led to lots of medication errors and sentinel situations (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). In the 2004 review by Rogers, Hwang, Scott, Aiken, & Dinges, it was found that the much longer the shift, the potential risks for errors boosts. Also, when working much longer than 17 hours without sleeping, nurse tiredness has been shown to demonstrate the equivalence to be under the impact with a blood vessels alcohol amount of 0. 05% (Garrett, 2008). The consequences of fatigue on nurses includes problems such as: affected problem-solving skills, reduced attention span, delayed reaction time, recollection lapses, impaired communication, and failure to target, which are very important to nurses to understand to be able to provide quality and safe patient health care (Warren & Tart, 2008). The evidences and problems of nurse exhaustion linked to undesirable incidents from the long work hours and cumulative days of prolonged work hours has been greatly acknowledged by The Joint Commission payment (TJC) issuing a sentinel event alert on Dec 14, 2011, regarding health care worker exhaustion and patient safeness (The Joint Commission payment, 2011). So, I am discussing the following in the paper that includes: reason of reviewable sentinel events, a specific sentinel event related to nurse tiredness, and its root cause analysis.

Explanation of Reviewable Sentinel Events

As described by TJC, a sentinel event can be an unexpected occurrence concerning either fatality, serious physical or emotional harm, or the risk thereof that prompts the necessity for immediate exploration and response (Sentinel Incidents Policy and Procedures, 2012). But, for a sentinel event to be considered reviewable, it must meet the following requirements:

the event resulting in an unanticipated fatality, coma, permanent loss of function, unrelated to the natural span of the patient's illness or underlying condition, or

the event is one of the next, but not limited to:

suicide within 72 hours to be discharged from a 24 hour care and attention setting

rape, sexual mistreatment/assault


abduction (Sentinel Events Policy and Types of procedures, 2012).

A Specific Sentinel Event Related to Nurse Fatigue

On July 5, 2006, Jasmine Gant, a pregnant 16 calendar year old senior high school student, arrived with her mother at St. Mary's Medical center in Madison, Wisconsin at 9:30 A. M. for her scheduled induction (Smetzer, Baker, Byrne, & Cohen, 2010). The Labor and Delivery (L&D) nurse designated to look after Ms. Gant that day was Julie Thao, 41 yrs. old. Mrs. Thao had been working at St. Mary's Medical center since 1993, and worked well in the L&D division for 15 years. Your day before July 5, 2006, Mrs. Thao had voluntarily functioned a double switch for a complete of 16 hours or more to protect for the unit's brief personnel. Mrs. Thao was extremely fatigued by the end of her transfer that ended at midnight. She spent the night at the hospital to avoid her hour long commute home and because she was due for her next shift at 7 A. M. Etc the morning of July, 5, 2006, the very fatigued nurse Mrs. Thao began her shift caring for one pregnant woman. When Ms. Gant shown at the L&D unit later that morning, Mrs. Thao spent time with her and her mother completing the entrance process that is performed with every admitting patient. However, Mrs. Thao did not apply a bar-coded id strap to Ms. Gant's arm at this time (Smetzer, Baker, Byrne, & Cohen, 2010). When speaking about pain management, Ms. Gant indicated the opportunity of wanting to use epidural, which Mrs. Thao would relay the meaning to the obstetrician.

At 11:30 A. M. , Ms. Gant's medical doctor showed up to her room to rupture her amniotic membrane. The medical doctor advised Mrs. Thao that he prepared to check back again before determining with the individual the need for epidural. In the meantime, he had bought Pitocin, Lactated Ringer's (LR) solution, and intravenous (IV) penicillin to treat a strep an infection that Ms. Gant acquired. While Mrs. Thao is at the room, the individual communicated to her that she was stressed about getting epidural. So, Mrs. Thao thought it might be smart to get epidural solution, Bupivacaine, showing the individual and in anticipation because the Anesthesiologist would get upset for devoid of it easily available.

Now, St. Mary's Medical center had just started transitioning and training the employees in using the newly installed club coded medication administration system. Apparently, the hospital was currently having problems with it, therefore the nurses were instructed to provide the medications when needed and report them personally. Well, Mrs. Thao bypassed the machine to eliminate the Bupivacaine, which she also did not have authorization or authorization to do so to the medication. Then, she obtained the LR solution and Pitocin before walking back into the patient's room. Along the way, another nurse handed her the IV penicillin. When Mrs. Thao got into the patient's room, she sat the equipment on the counter and began to prepare and start the IV infusion. Carelessly, Mrs. Thao made the fatal miscalculation and grabbed the epidural solution instead of the penicillin, both looking virtually identical in appearance, administering it intravenously into Ms. Gant's arm. Unknowingly of the blunder she acquired just done that would soon cost her nursing profession and her patient's life, Mrs. Thao went on to rewinding the tape on the birthing process that can be played for the patient, her mother, and the baby's daddy who experienced just arrived creating plenty of tension. Within a few minutes, the patient's mother terrifyingly screamed for mercy. At this point, her daughter was at respiratory distress, seizing, and into a cardiac arrest. The frantic nurse immediately called the rapid response team and code blue. Every effort was made to resuscitate Ms. Gant, but she remained asystolic. Ms. Gant was immediately taken up to the operating room with an disaster cesarean section where the physicians shipped an 8 pound healthy baby boy. The health treatment team prolonged resuscitating Ms. Gant, but was pronounced useless by 1:43 P. M. After ruling out several possible causes of her fatality, it was uncovered minutes later that the infusing tote was the epidural solution, rather than the penicillin (Smetzer, Baker, Byrne, & Cohen, 2010). Her fellow workers reported that Mrs. Thao looked extremely fatigued, which possibly increased her probability of making the fatal medication mistake along with the omission to confirm the five privileges of medication administration.

The Root Cause Analysis

A root cause analysis (RCA) is a technique used to help identify the possibilities of causes that led to the end result. Whenever a sentinel event occurs, the hospital is responsible to execute a root cause research. The point of RCA is not to point out who's at fault. Thus, by performing a RCA, it allows for an idea of action to avoid the same or similar occurrences from developing. The first part of the RCA is determining the situation or effect. Part two is determining why it just happened with the cause and effect approach. Part three is creating solutions and implementing an idea of action to reduce the probability of the function from happening again.

In the sentinel event above, the problem was a medication error by registered nurse (RN) Julie Thao that possessed resulted in the maternal loss of life of 16 year old expectant mother, Jasmine Gant. The four cause categories formulated for this specific circumstance are: people, work environment, equipment, and policies and types of procedures.

The nurse Mrs. Thao's fatigued acquired a tremendous influence on the actions leading to the medication problem. She possessed voluntarily worked well a back again to back change of 16 time or more the night time before starting work again the next morning. She expressed the desire to go home halfway through her second change, too. While caring for Ms. Gant, the nurse was sidetracked while setting up the medications. Mrs. Thao reported that there is pressure in her patient's room when the baby's dad came, so she had intended to administer the IV penicillin and put on the educational video tutorial of the birthing process.

The work environment of the L&D unit that Mrs. Thao worked on was not well-organized. The nurses didn't directly talk to the Anesthesiologist rendering it difficult to have the epidural ready after their arrival. The unit was also brief staffed with several nurses on short-term leave (Smetizer, Baker, Byrne & Cohen, 2010). If Mrs. Thao had not worked second shift, they might have been inadequately staffed. The staff and managers did not purely enforce and adhere to the policies such as the identification rings and pub code medication supervision system.

So, the issues from the policies and steps included the hold off of the patient's recognition bar code band program, omission of verifying the five privileges of medication administration, and retrieving the epidural before it was bought. The issue with the wait of the patient's id band was that it required much longer for the bands to be made with the new system. The staff and management were lenient and managed to get a norm to place it on the patient whenever it was a convenient time. However, Mrs. Thao confessed that she didn't adhere to the five rights of medication administration. Also, she retrieved the epidural before it was ordered to decrease her patient's dread and in anticipation of early on epidural. Retrieving the epidural in expectation upon the Anesthesia's appearance was a common practice on the L&D floor as a result of dissatisfaction indicated by some Anesthesiologist from it not being readily available.

For equipment, there was the problem of the newly installed bar code medication administration system and the design of the carrier of epidural solution and IV penicillin. The brand new system's continuous problems created low rates on compliance on scanning IV carriers, and nurses bypassing the system, which included safe practices features to avoid such errors from happening. The L&D device staff had insufficient training on troubleshooting the machine, especially Mrs. Thao. Instead, management allowed them to hold the medications and file them manually. Together with the mistake of getting the wrong handbag, Mrs. Thao had brought all the products including the two luggage from the anteroom and sat them onto the counter-top near the patient's bedside so that she can speak to the patient directly. The bag including the epidural solution and the tote of the penicillin appeared similar in proportions, but the epidural was slightly bigger. These were both clear alternatives. The two bags both possessed orange label stickers, however the epidural bag possessed an additional bright pink warning label. There is also a design flaw in the interconnectivity making the IV tubes compatible with being able to access the epidural bag port enjoy it does indeed with the IV alternatives (Smetizer, Baker, Byrne & Cohen, 2010).

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