A Sentinel Event Related To Nurse Fatigue Nursing Essay

A Sentinel Event Related To Nurse Fatigue Nursing Essay 12 hour shifts, extended work periods, voluntary and mandatory overtime, and excessive workloads are all factors that dangerously contribute to nurse fatigue, which has led to a number of medication errors and sentinel events (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). In the 2004 study by Rogers, Hwang, Scott, Aiken, & Dinges, it was found that the longer the shift, the risks for errors increases. Also, when working longer than 17 hours without sleep, nurse fatigue has been shown to demonstrate the equivalence of being under the influence with a blood alcohol concentration of 0.05% (Garrett, 2008). The effects of fatigue on nurses includes problems such as: compromised problem-solving skills, decreased attention span, delayed reaction time, memory lapses, impaired communication, and inability to focus, which are all important for nurses to be aware of in order to provide quality and safe patient care (Warren & Tart, 2008). The evidences and dangers of nurse fatigue linked to adv erse events from the long work hours and cumulative days of extended work hours has been greatly recognized by The Joint Commission (TJC) issuing a sentinel event alert on December 14, 2011, regarding health care worker fatigue and patient safety (The Joint Commission, 2011). So, I will be discussing the following in the paper that includes: explanation of reviewable sentinel events, a specific sentinel event related to nurse fatigue, and its root cause analysis. Explanation of Reviewable Sentinel Events As defined by TJC, a sentinel event is an unexpected occurrence involving either death, serious physical or psychological harm, or the risk thereof that prompts the need for immediate investigation and response (Sentinel Events Policy and Procedures, 2012). But, for a sentinel event to be considered reviewable, it must meet any of the following criteria: the event resulting in an unanticipated death, coma, permanent loss of function, unrelated to the natural course of the patientâ⠂¬â„¢s illness or underlying condition, or the event is one of the following, but not limited to: suicide within 72 hours of being discharged from a 24 hour care setting rape, sexual abuse/assault elopement abduction (Sentinel Events Policy and Procedures, 2012). A Specific Sentinel Event Related to Nurse Fatigue On July 5, 2006, Jasmine Gant, a pregnant 16 year old high school student, arrived with her mother at St. Mary’s Hospital in Madison, Wisconsin at 9:30 A.M. for her scheduled induction (Smetzer, Baker, Byrne, & Cohen, 2010). The Labor and Delivery (L&D) nurse assigned to care for Ms. Gant that day was Julie Thao, 41 years old. Mrs. Thao had been working at St. Mary’s Hospital since 1993, and worked in the L&D department for 15 years. The day before July 5, 2006, Mrs. Thao had voluntarily worked a double shift for a total of 16 hours or more to cover for the unit’s short staff. Mrs. Thao was extremely fatigued by the end of her shift that ended at midnig ht. She spent the night at the hospital to avoid her hour long commute home and because she was due for her next shift at 7 A.M. So on the morning of July, 5, 2006, the very fatigued nurse Mrs. Thao started her shift caring for one expectant mother. When Ms. Gant presented at the L&D unit later that morning, Mrs. Thao spent time with her and her mother completing the admission process that is done with every admitting patient. However, Mrs. Thao did not apply a bar-coded identification band to Ms. Gant’s arm at this time (Smetzer, Baker, Byrne, & Cohen, 2010). When discussing pain management, Ms. Gant expressed the possibility of wanting to use epidural, which Mrs. Thao would relay the message to the obstetrician.