Perceptions of Sentinel Event Case Study Analysis
Description
Scenario
You finished new graduate orientation yesterday on a general medical surgical unit, and today you will independently care for two clients. As you receive a report on the second client at 0730, your Preceptor stops by to ask how the first day by yourself is coming along and reminds you to complete the final items on your training list today before the end of the 12-hour shift.
Complete the new online training model and quiz on the sliding insulin scale
Complete the orientation evaluation form
- Sign up for one of the four nursing committees
- Complete and sign the orientation reflection journal
- Attend the new employee luncheon from 1-2 pm sponsored by the hospital physicians
- Client 1
- 25 year old female 24 hours post-op from a Roux-en-Y gastric bypass
BMI of 50
History of hypertension and sleep apnea
- No complications post-operative
- Pain at 4 am, three on a scale of 10
- Nasogastric tube to gravity
- NPOMother stayed overnight but left early this morning to shower and will return later in the afternoon
- Waiting on morning labs
- Client 2
- 46 year old male admitted 72 hours prior with severe GERD and difficulty swallowing
- History of alcoholism, hypertension
Smoked two packs per day for 22 years
Endoscopy for Barrett’s Esophagus was negative on the day of admission
- Pain at 4 am, two on a scale of 10
- Due to resume clear liquid diet this morning
- Potential discharge later today home with family
- The ex-wife has stayed in a room with a client and has been disruptive at times demanding pain medication and food.
- Waiting on morning labs
- Client 1
- Physician orders:
- Dietary Consult
- Bariatric Behavioral Therapist Consult
0.45% NS intravenous infusion post op
Client 2
Medications:
- Protonix 40 mg once daily, intravenous infusion
- Switch to oral Protonix 40mg day of discharge
- IV infusion 0.9% NS 50 ml/hour
Resume 50mg Lopressor (metoprolol) PO twice daily after rule out Barrett’s Esophagus
1-2mg Morphine Sulfate IV PRN q 4-6 hours for pain greater than 6 out of 10
TIME (EVENT)
- 0800 – You prioritize the need to assess the 46 year old male first since he has 0900 medications and the physician is rounding and should order discharge today. Assessment and vital signs reveal no concerns, ex-wife not present. A physician writes an order to discharge this client today. The client asks you to return in 30 minutes and go over discharge when ex-wife is present to hear instructions. You administer Lopressor and Protonix.
- 0830 – You assess the 25 year old post bariatric surgery client. Vital signs and morning labs are within acceptable limits, and client reports pain two on a scale of 10. While assessing for bowel sounds, you notice the nasogastric (NG) tube not secured to the nose, and the client reports the tube partially came out when she blew her nose but she was able to push it back in with no pain. You document NG tube in place and assist the client to the bathroom.
- 0900 – You return to 46 year old client and review discharge instructions with the client and ex-wife, discontinue the IV infusion, remove the intravenous catheter, and complete discharge summary.
- 0945 – Transport stops by to take 25 year old client to meet with a support group for bariatric surgery clients — you okay transport.
- 1000 – Physician stops into see a bariatric client and is upset you let her leave for support group before rounding. You report no concerns, physician reviews chart and writes discharge order for later in the afternoon if no vomiting or pain. The NG tube can be removed at noon by the Nurse Practitioner, and a diet of clear liquids resumed at 6 pm if no vomiting or gastric distention. Call immediately if any vomiting or signs of gastric distention occur.
1030 – You take a break to complete orientation reflection journal, orientation evaluation, and online sliding insulin scale training module and quiz.
1130 – The 25 year old bariatric client returns from the support group, you see her ambulating in the hallway, and you notice the NG tube is missing. The client states the tube fell out of her nose when she stood up to introduce herself. She has no complaints of nausea and no evidence of gastric distention. You document the NG tube was removed accidentally by the client.
1200 – 46 year old male client calls and expresses frustration at a time to discharge. He wants to be home by 3 pm for his son’s birthday party. You call transport who assures you and the client they will arrive before 1 pm to discharge the client.
- 1215 – Morning documentation complete, all orders are in the system, and both clients are stable. You are amazed at how smooth the first day is going. You head to the new employee luncheon with your Preceptor.
- 1330 – You return from lunch and find the 46 year old client discharged, and you must prepare for a new admit from the emergency room with rule out pancreatitis. You feel apprehension since this will be your first admit, so you reach out to your Preceptor to review policy and procedure for new admissions.
- 1345 – While working with your Preceptor, the Certified Nursing Assistant stops by and reports the 25 year old client refused an afternoon visit from a member of the bariatric support group, complaining of fatigue. Her noon vital signs were blood pressure 90/40, heart rate 112, and respiratory rate 28. Your Preceptor assures you these vital signs, and fatigue often occurs with this type of client. She susgest, the client is probably depressed, ready to go home, and suggests to let her rest for the afternoon.
- 1415 – The new admit from the emergency department arrives with two pages of physician orders and a communication challenge since he speaks and understands only Spanish. He has pain in the abdomen and begins vomiting. Seeing you are now very busy, the Preceptor offers to “look in” on your 25 year old client and will take care of any concerns. Also, she will order a translator to assist with the new admit, while you focus on taking care of the physician orders.
- 1730 – Finally, all orders for the new admit are in the system; pain decreased, no further vomiting, and he is resting comfortably. While waiting for lab results, you decide to check on the 25 year old client.
- 1745 – On the way to the client’s room, the Nurse Manager stops and asks you to take a moment to fill out a volunteer form for one of the four nursing committees on the Unit.
- 1815 – You return to the 25 year old client’s room and find her unresponsive, pale, with no heart beat or respirations. The abdomen is distended and hard. Attempts are made for resuscitation but are not successful. The client is deceased.
- 1900 – You prepare to leave to go home. The Nurse Manger stops you and asks to debrief the situation. After reviewing the chart and discussing the situation, she is concerned and sees errors in your judgement and actions. She is sure the client’s death will be a sentinel event and warrant a review by the Internal Review Board.
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