A nurse manager is planning to request two new mechanical ventilators at a cost of approximately $50,000 each. This item would typically be included in which budget?

Choice A Reason:

The wrong operation was performed on a patient. This incident is a clear example of a sentinel event. According to The Joint Commission, a sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm and requires immediate investigation. Performing the wrong operation on a patient is a serious error that can lead to significant harm or even death, making it a sentinel event.

Choice B Reason:

A client received an incorrect dose of medication, but it did not result in injury. While administering an incorrect dose of medication is a medication error, it does not qualify as a sentinel event if it does not result in harm. Sentinel events are defined by the severity of the outcome, and in this case, the lack of injury means it does not meet the criteria.

Choice C Reason:

A patient complains that a nurse was rude and abrasive. Although this behavior is unprofessional and can affect patient satisfaction and trust, it does not constitute a sentinel event. Sentinel events are related to significant harm or risk of harm to the patient, which is not the case here.

Choice D Reason:

A nurse withholds a medication upon suspecting that the patient may be allergic to the drug. This action is a precautionary measure taken to prevent potential harm and is not a sentinel event. In fact, it demonstrates good clinical judgment and adherence to patient safety protocols.

Choice A reason:

Motivating nurses to submit incident reports and include them in patients’ records is important for transparency and accountability. However, this approach alone does not address the root causes of medication errors. Incident reporting is a reactive measure that helps in documenting errors after they occur but does not proactively prevent future errors. Effective error reduction requires a more comprehensive strategy that includes identifying and addressing the underlying factors contributing to errors.

Choice B reason:

Delegating the task to another department to manage quality improvement might seem like a viable option, but it can lead to a disconnect between the staff directly involved in patient care and those responsible for quality improvement. This separation can result in a lack of ownership and accountability among the nursing staff. Quality improvement initiatives are most effective when they involve the active participation of the staff who are directly involved in the processes being improved.

Choice C reason:

Working together with floor nurses to identify the causes of errors and develop solutions is the most effective approach. This collaborative method ensures that the staff who are directly involved in patient care are engaged in the process of identifying issues and creating practical solutions. Nurses on the floor have firsthand knowledge of the challenges and can provide valuable insights into the factors contributing to medication errors. This approach fosters a culture of teamwork, continuous improvement, and shared responsibility for patient safety.

Choice D reason:

Preventing errors by highlighting the punishments for making a medication mistake is a punitive approach that can create a culture of fear and blame. This method is counterproductive as it discourages open communication and reporting of errors. When staff fear punishment, they are less likely to report mistakes, which hinders the ability to learn from errors and implement preventive measures. A more effective strategy focuses on creating a supportive environment where staff feel safe to report errors and participate in developing solutions.