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.
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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Related Questions
Correct Answer is C
Explanation
A. Restrain patients at risk for falls: Restraining patients can lead to physical and psychological harm and is not an evidence-based intervention for fall prevention.
B. Recognize that errors are solely the result of the actions of individual people: This approach ignores systemic issues and does not address the root causes of falls, making it an ineffective strategy.
C. Provide an in-service that informs nurses of the current, best practices of fall prevention: Educating staff on best practices for fall prevention is an evidence-based intervention that can help reduce the number of falls.
D. Punish the staff who are caring for the patients who fall: Punishment creates a blame culture, which can reduce staff morale and does not effectively address the factors contributing to falls.
Correct Answer is A
Explanation
A. Incidence of catheter-induced urinary tract infections: Outcome audits measure the results or outcomes of care, such as the incidence of infections, reflecting the effectiveness of care interventions.
B. Nursing staff ratios: This pertains to a process or structure audit, which examines staffing levels and their adequacy rather than the outcomes of care.
C. Availability of resources, such as fire extinguishers: This is assessed by a structure audit, focusing on the availability and adequacy of resources rather than client care outcomes.
D. Quality of nursing care provided: While important, quality of care is typically assessed through various audit types including process and outcome audits, and is not specifically categorized under outcome audits alone.
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