Any facility that is accredited by the Joint Commission must conduct a root cause analysis (RCA) in the case of a sentinel event. According to the Joint Commission (2013), a sentinel event is “is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” In the case study presented, a rural emergency department (ED) has a patient who experiences a sentinel event. There were several factors involved in the deterioration of the patient. The most important factor was the inadequate monitoring of the patient following sedation. The patient did not receive appropriate care as required by hospital procedure. The lack of appropriate treatment and monitoring after sedation was the root cause of the sentinel event.

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The hospital ED lacked sufficient RNs at the time of the sentinel event. The RN in the ED, Nurse J. should have called for an additional RN upon notification by the paramedics of an incoming patient in respiratory distress. She was already treating a pediatric patient with appendicitis, a patient who was scheduled for discharge and Mr. B., the patient under sedation. She only had an LPN to assist her. The hospital policy allowed her to request assistance. She failed to do so, creating a risk for the patients. “Optimal staffing is essential in order to provide optimal patient care” (American Nurses Association, 2013).

The patient was heavily sedated. Per hospital standards, the patient required oxygen and full monitoring, including EKG. The nurse failed to provide these for the patient. Even without the hospital requirement, the patient’s O2 sat was originally 92%. According to ACLS, the goal is 94% or greater for O2 sat (American Heart Association, 2010). This is particularly true for individuals undergoing sedation or anesthesia. The patient’s oxygen saturation alarm sounded; the LPN merely reset the alarm. At this point, the patient was severely hypoxic and should have been thoroughly assessed and treated by the RN and MD. At this point, with proper intervention, the patient may not have arrested. According to the World Health Organization (2011), a pulse ox reading below 90% is a critical emergency and requires immediate treatment. At this point, the MD and respiratory therapist needed to be called to treat the patient. The cardiac arrest and sentinel event could have been prevented at this point with aggressive intervention.

Lewin’s theory of change requires three stages: unfreeze, transition and freeze. It is important to unfreeze the attitudes of management regarding proper staffing. It is also important to unfreeze the attitudes of nurses with regards to “routine” sedation. While patients are routinely sedated, there is nothing “routine” about this procedure for the human body. These aspects need to be transitioned into new attitudes in the hospital. This would include extensive clinical practice changes and also safety protections. The safety protections may include the use of electronic records. If the patient is sedated per the records, the system may trigger an alarm regarding the use of monitoring equipment. This may remind the nurses of the importance of the monitoring. In addition, as the new procedures are done repeatedly, they will become a regular aspect or ‘frozen’ (Nursing theories, 2013).

A failure mode and effects analysis (FMEA) is also required. The team should include members of nursing, nursing administration, emergency physicians, hospital physicians, respiratory therapists and hospital administration. The pre-steps for the meetings including identifying all hospital protocols surrounding sedation. It also includes identifying how often they are followed. The new process can be tested through the use of electronic health records. The records can be reviewed for use of proper monitoring with any patients who receive sedation. The worst case scenario under severity has already occurred. A patient arrested as a result of improper care. It was a critical error. If the system is designed properly, lack of monitoring will always be detected. The RN will have to enter the information regarding EKG data and monitoring for all sedated patients. Ideally, the system can be later designed to include automatic inclusion of the EKG data into the system. If the data was automatically entered from the monitoring system, it would guarantee that the patient was monitored appropriately. With the new system, it is very unlikely that similar occurrences would happen. The only possible way for it to occur is if the RN is allowed to manually override the request for the information. This should not be allowed. Anytime an order for a sedative is entered into the computer system, it should trigger the need for information on monitoring the patient. For instance, when valium is ordered for a patient, the computer system should immediately request information on the patient’s oxygen saturation, EKG rhythm, and the administration of oxygen delivery to the patient. The only other way would be if the RN falsified the records and indicated monitoring was used when it was not.

As the primary source of clinical patient care, nurses would be heavily involved in ensuring this sentinel event did not repeat itself. Nurses are the health care providers who continuously monitor patients for changes in condition. They are the ones who must decide when and if to notify the physician of a change in the patient’s condition. As a result, the nurse is the one who is needed to ensure that these steps are followed. It is also important to ensure that an RN is notified by the LPN when the patient’s monitors alarm. If the LPN had not silenced the alarm, the patient may not have arrested from low oxygen levels. Obviously, additional training for the LPNs on staff is also warranted. An LPN should not fail to recognize the severity of a pulse oximetry reading of less than 85%.

Sentinel events need to be thoroughly assessed by all facilities. Unfortunately, sentinel events can normally be prevented. When they are not prevented, the patient suffers a life- or limb-threatening adverse outcome. In this tragic scenario prevented, the patient died. This was completely unnecessary. If the patient had been properly treated with oxygen and properly monitored, the outcome likely would have been favorable for this patient.

  • American Heart Association. (2010). Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Retrieved December 27, 2013, from:
  • American Nurses Association. (2013). Nurse staffing. Retrieved December 28, 2013, from:
  • Joint Commission (2013). Sentinel event. Retrieved December 27, 2013, from:
  • Nursing Theories. (2013). Change theory. Retrieved December 28, 2013, from:
  • World Health Organization. (2011). Pulse oximetry training manual. Retrieved December 28, 2013, from: