A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event?

Surgery to the wrong site was stopped prior to a procedure.

Paralysis of a client's lower extremities occurred following epidural anesthesia.

A client fall during ambulation did not result in client injury.

A complaint that a nurse was culturally insensitive was made by a client's family member.

Answer and Explanation

The Correct Answer is B

A. Surgery to the wrong site was stopped prior to a procedure: This incident was prevented before harm occurred and is not considered a sentinel event since no actual harm was inflicted.
B. Paralysis of a client's lower extremities occurred following epidural anesthesia: This represents a significant adverse outcome that has resulted in severe harm and is considered a sentinel event, which requires thorough investigation and response.
C. A client fall during ambulation did not result in client injury: Although falls are a concern, the lack of injury means this incident may not be classified as a sentinel event.
D. A complaint that a nurse was culturally insensitive was made by a client's family member: While important for addressing care quality and communication, this complaint does not typically constitute a sentinel event as it does not directly involve significant harm or risk.

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Correct Answer is A

Explanation

A. Involve affected staff in the decision-making process: Involving staff in decision-making aligns with complexity principles, which emphasize collaboration and the consideration of multiple perspectives to address complex issues effectively.
B. Focus the assessment on the unit and do not consider the hospital as a whole: Ignoring broader organizational factors may limit the effectiveness of adaptations and does not fully consider the complexity of the hospital environment.
C. Create a mandatory policy to force workers to participate in problem-solving solutions: Mandating participation without engagement may lead to resistance and does not align with complexity principles that value collaboration and buy-in.
D. Select a management approach that does not change: Maintaining the status quo may fail to address the unique needs of older adults and does not reflect the adaptive nature of complexity principles.

A. Review the events leading up to each medication administration error. B. Require staff nurses to demonstrate competency by passing a medication administration examination. C. Develop a quality improvement program for nurses involved in medication administration errors. D. Provide an inservice on medication administration to all the nurses.

Correct Answer is A

Explanation

A. Review the events leading up to each medication administration error: Analyzing the events that led to medication errors helps identify root causes and contributing factors, which is crucial for developing targeted interventions and improving practices.
B. Require staff nurses to demonstrate competency by passing a medication administration examination: While competency is important, it should be based on insights gained from reviewing errors and understanding specific areas needing improvement.
C. Develop a quality improvement program for nurses involved in medication administration errors: This is a valuable step but should come after understanding the underlying causes of the errors through a review process.
D. Provide an inservice on medication administration to all the nurses: Training is important, but it should be informed by the findings from the error review to address specific issues and improve practices effectively.

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A nurse is a member of a quality-improvement committee seeking to reduce the risk of adverse events in a health care facility. When reviewing recently submitted incident reports, which of the following incidents should the nurse identify as a sentinel event?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager of a 20-bed medical unit finds that 80% of the patients are older adults. She is asked to assess and adapt the unit to better meet the unique needs of the older adult patient. Using complexity principles, what would be the best approach to take for implementation of this change?

Correct Answer is A

Explanation

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

Correct Answer is A

Explanation

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