Sentinel Perioperative
Patient’s safety is one of the key targets of healthcare. Sometimes, it becomes an issue of concern to witness the ideal deal of safety in the hospital be thrown away by mistakes that could be prevented. Despite numerous steps taken by healthcare to prevent small but serious mistakes in medication, there exists a big gap between the effective safety and wellbeing of patients. It is the role of hospitalists to uphold the laid measures. Sages say that human is to error; however, there should be an ultimate goal of observing the right conduct as the medical profession. The issue of sentinel perioperative is not an easy term to define since it revolves around numerous aspects, but all centered towards a common notion of safety. Different authors have written about patient’s safety by addressing the menace of sentinel perioperative. Nonetheless, the patient’s safety is a basic component in healthcare that should be not gambled by anybody.
Joen Pritchard Kinna’s article “Sentinel Events” have a lot of information concerning the topic. To get in the deep part of Kinna’s article, he describes sentinel event as an unexpected occurrence which may either result in sudden death or critical physical or/and psychological injury later. The term has been in the mainstream of healthcare for many years, only that the issue has increased its concerns in the 21st century. The article starts with a case where a teenage lady, whose name has been banned, who became a victim of sentinel perioperative event. According to the author, a certain teenage lady visited Madison, Wis. Hospital to deliver. However, the mother-to-be passed away a few hours after being admitted to the hospital. Luckily, her child survived. The proceeding investigations found that the deceased had died due to wrong medication. Wisconsin State Department of Health said that “the young lady had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given”. A nurse said that the patient was nervous about the medication. Unluckily, the nurse confused the bag with the right medication, hence creating such a heartbreaking mistake.
The above sentinel event is as a result of a mistake that resulted in a medication error. It is a common but devastating type of mistake in the healthcare system. Medication errors are so grievous that the impact can affect the wellbeing of patients and society. According to a report by Preventing Medication Errors, prepared by the Institute of Medicine (IOM), about 1.5 million people are affected by a medication error in the United States of America annually. Additionally, the same report further tallies thousands of deaths per year as the government is left to pounder on a loss of about $3.5 billion each year.
However, medication mistakes can be prevented by being keen on medication packages. For example, the above case was propelled by a mistake that could have confused the nurse in the determination of the correct medication bag. Besides, medication ordering should be precise, clear, and well-tagged so that there cannot be such medication. The author supports his insights by presenting data by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) shows that “At least a quarter of medication-related injuries are preventable”. However, the irony comes in where numerous medications are not well-labelled and sorted out to ease their access.
The case has reminded me of the importance of patient’s safety from every bit of the healthcare unit. Hospitalists should be in the front line to cater to the patients’ wellbeing. Medication error is an unforgivable mistake that should not be tolerated at any given time. Unless, the responsible sector in the healthcare system uphold the patients’ safety charter, the same mistake will keep on reoccurring. Nonetheless, sentinel perioperative events can be prevented.
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