Sentinel Events In Nursing Care: A Case Study

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According to the Joint Commission (2006), a sentinel event is as, “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or “risk thereof” includes any process variation for which a recurrence carries a significant chance of a serious adverse outcome.” Sentinel events signal a need for immediate investigation and response. The importance of sentinel events in providing safe nursing care includes: improving quality of patient care, increasing the awareness of sentinel events, upholding the public trust of the medical system and understanding the reason behind the event and restructuring the organizations protocols in possible future events. As the safety officer appointed by Doctor Dover, the head of Johns Hopkins Children’s Center, I led…show more content…
Drowning ranks as the third cause of accidental death in toddler girls (Hockenberry & Wilson, 2011, p. 579). Toddlers are extremely mobile and able to access dangerous areas such as bathtubs, swimming pools, ditches, hot tubs and ponds. They are extremely precocious and will lean over the side of bathtubs, pools and with their heavy heads, limited strength and poor coordination; it makes it difficult for them to prevent their own injury. They have a desire to explore and when you couple that with an unawareness of the dangers of water and their inability to save themselves in water, it makes drowning a very real threat. Death can occur in minutes which decrease the chance of rescue or survival. According to Hockenberry and Wilson (2011), “supervising children when near any source of water is essential” (Hockenberry & Wilson, 2011, p. 579). If Josie had been accompanied by an adult her injury could have been avoided, or at the very least, the amount of her exposure to the scalding water would have been

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