RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE, KARNATAKA,

BANGALORE.

APPLICATION FOR APPROVAL OF PROJECT PROPOSAL.

1. / Name of the Candidate & Address / LOUKRAKPAM URMILA DEVI.
PADMASHREE COLLEGE OF HOSPITAL ADMINISTRATION
2nd FLOOR, RAJANNA BUILDING,NAGARBHAVI CIRCLE, BANGALORE- 560072
2. / Name of the Institution / PADMASHREE COLLEGE OF HOSPITAL ADMINISTRATION.
3. / Course of Study and Subject / MASTERS IN HOSPITAL ADMINISTRATION.
4. / Date of Admission to Course / 05/10/2010.
5. / TITLE OF THE TOPIC:
“A STUDY TO ASSESS THE ROLE OF NURSES IN PREVENTING SENTINEL EVENTS IN A SELECTED HOSPITAL.”
6. / DEFINITION AND SCOPE OF STUDY :
There is always a possibility of occurrence of adverse events even in the best of healthcare organizations. What is more important is to continuously examine the systems and processes that increase the possibility of adverse events and re-design the system to reduce the risk.
The Joint Commission defines a sentinel event as“An unexpected occurrence involving death or serious physical or psychological injury includes loss of limb or function. The phrase, ‘or the risk thereof ‘includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.”
Medical errors have been present in healthcare since the beginning of time. The real tragedy is that most of the medical mistakes are preventable. They are most often caused by systems that break down and don’t support the highly qualified and dedicated hospital caregivers the way they should.
The sentinel events may result from the acts of commission or omission. An error of commission occurs when wrong action is taken and omission when there is failure to take the required action or the same is delayed. For example, giving wrong medication to a patient will be error due to act of commission and failure to give the medicine or delay in giving the medicine will be the error due to the act of omission.
All nurses, in all healthcare settings, play a key role in the prevention of these errors.Referencecomplete with tools to prevent medical errors is offered to all nurses ranging from staff nurses to chief nursing officers.
In April 2002, the Joint Commission (JCAHO) appointed a panel of physicians, nurses, pharmacists, and other patient safety experts to advise the organization on developing its first set of national patient safety goals.
According to JCAHO – the national safety goals are asfollows-----
  1. Improve the accuracy of patient identification.
  2. Improve the effectiveness of communication among the caregivers.
  3. Improve the safety of using high-alert medications.
  4. Eliminate wrong site, wrong patient, and wrong procedure surgery.
  5. Improve the safety of using infusion pumps.
  6. Improve the effectiveness of clinical alarm systems.
Patient safety is a serious global public health issue. Estimates show that in developed countries as many as one in 10 patients is harmedwhile receiving hospital care. Patient safety is such an important part of our healthcare system and it helps define quality healthcare. Patient safety is now one of the most important factors in the modern day hospital, and the recent crisis with the infections spreading through wards has put doctors, nurses, and surgeons, on high alert.
Thus, the study on the sentinel events occurring in the hospital which is generally taken as an unexpected or unwanted events(adverse events) and its prevention is important because this will help the organizations to identify and conduct a timely root cause analysis of all reviewable sentinel events and implement an action plan so that the same is not repeated in the future. And to describe the various ways a nurse can intervene and speak up to prevent errors and begin to effect a change in the care given to the patient.
7 / OBJECTIVE OF THE STUDY:
  1. To assess the awareness of the nurses on prevention of sentinel events.
  1. To assess the safety precautions taken by the nurses in preventing such events.
  1. To identify the different approaches hospital has adopted to educate the nurses on sentinel events and its prevention.

8. / RESEARCH METHODOLOGY:
This is a descriptive study. The primary data will be collected by personal observation and by giving questionnaire to the nurses and by interviewing the top management of the hospital. The secondary data will be collected by going through the relevant records maintained in the department.
9. / REVIEW OF LITERATURE:
With the advances of innovative health technology in patient management and specialized patient care, the provision of healthcare is becoming more complex with many interconnected care processes. This gives risk to the potential occurrence of sentinel events.1
The November 1999 Institute of Medicine (IOM – 1) report, To Err is Human: Building a Safer Health System, noted that a major barrier to improving safety is a lack of awareness of the problem. This is due to inadequate reporting of errors and the resulting inability to accurately measure their occurrence. Starting in 1998, the Joint Commission (JCAHO) began requiring the reporting of one specific type of medical error or serious adverse event termed a sentinel event.2
A SENTINEL EVENT is defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient’s illness.3
Joint Commission has laid down a policy for two category of events. The reviewable and non-reviewable sentinel events under Joint Commission policy are as under:
  1. Reviewable Sentinel Events
  • Death/permanent major morbidity due to medication error.
  • Suicide including 72 hours after discharge.
  • Homicide/assault resulting into major permanent loss/unauthorized absence from the hospital.
  • Wrong site surgery
  • Intra-partum maternal death.
  • Peri-natal death in an infant having birth weight more than 2.5 kg (without any congenital defect)
  • Abduction
  • Fall leading to major disability/death
  • Blood transfusion reaction involving major blood group incompatibilities.
  • Foreign body left inside the body during surgery.
  1. Non Reviewable Sentinel Events
  • Near miss.
  • Reversal loss due to adverse event.
  • Any sentinel event that has not affected an individual.
  • Medication errors that have not resulted into major loss of function or death.
  • Death or loss of function following discharge against medical advice.
  • Unsuccessful suicide.
  • Minor haemolysis.4
Nurses play an important role in delivery of care and their unique opportunity and responsibility to identify potential sentinel events. It includes preventing medication and transfusion errors, as well as preventing suicide, falls and treatment delays. Nurses learn how to
  1. Better recognize the root causes of specific sentinel events.
  2. Identify strategies to prevent sentinel events from occurring.
  3. Overcome obstacles in the area of staffing, training, culture of safety, and communication among the healthcare team.5
Most of the strategies offered are practical; however, some will be more challenging to tackle than others. Front line of Defense should be available to all nurses in their work-place. It is particularly helpful in providing a thorough examination of the various root causes that may not come to mind when reviewing errors.6
According to the Institute of Medicine, medical error resulted in as many as 98,000 preventable deaths per year; twice the rate of traffic fatalities and the estimated cost in the US could be almost 29 billion dollars (Wells, 2001). In the long run, Society, patients themselves, physicians, nurses, nursing professors, administrators, researchers, physicians, or professional associations, all of these entities are responsible for making sure the patient has the safest possible outcome. This is a nationwide and worldwide issue that will never be completely resolved because error is always prone to happen.7
10. / LIST OF REFERENCES:
  1. (accessed on 09/06/2011)
  2. (accessed on 09/06/2011)
  1. Accessed on 07/06/2011)
  1. Misra UB, Chakravarty A, Kant Sunil. “Patient Safety in Hospitals: Principles & Practice”, published by Department of Hospital Administration Armed Forces Medical College, Pune, 2009,page no. 39 & 40.
  2. (accessed on 11/06/2011)
  3. Porche Jr RA, Terrace Oakbrook, Front line of Defense: The Role of Nurses in Preventing Sentinel Events ,2nd edition, Critical Care Nurse, Reviewed by Mary Pat Aust RN,MS NO.6, 2007; pg no.27 – 75
  4. (accessed on 08/06/2011)

11 / SIGNATURE OF CANDIDATE:
12 / REMARKS OF PROJECT GUIDE:
13 / NAME AND DESIGNATION OF:
13.1 SUPERVISOR : Ms.SUPREETHA CASTELINO
Associate Professor.
13.2 SIGNATURE :
13.3 CO-SUPERVISOR (if any):
13.4 SIGNATURE :
14 / NAME OF THE PRINCIPAL:
Ms. Reshma Lobo
Padmashree College Of Hospital Administration
Bangalore-72
REMARKS :
SIGNATURE :

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