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 What is a sentinel event?
 ‘Sentinel event’ refers to a subset of serious clinical incidents that have
caused or could have caused serious harm or death of a patient. It
refers to preventable occurrences involving physical or psychological
injury, or risk thereof.
 Sentinel events are 10 specific types of clinical incidents:
 Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death.
 Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or
death.
 Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or
death.
 Unintended retention of a foreign object in a patient after surgery or other invasive procedure
resulting in serious harm or death.
 Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or
death.
 Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward.
 Medication error resulting in serious harm or death.
 Use of physical or mechanical restraint resulting in serious harm or death.
 Discharge or release of an infant or child to an unauthorised person.
 Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death
 Facing a Sentinel Event Head-on (What to Do When an Event Occurs)

 Step 1: Secure the situation - Ensure the patient and staff's well-being is
being cared for.
 Step 2: Preserve anything that might be helpful in the investigation - for
example, equipment, tubing, medications.
 Step 3: Disclose the situation and relevant information to the patient or
caregiver.
 Step 4: Provide support for the patient, family, and staff.
 Step 5: Follow The Joint Commission's reporting and root-cause analysis
requirements, detailed in the organization's accreditation manual. A root-
cause analysis should be performed as soon as possible after the sentinel
event.
ANECDOTAL RECORD
 Definition
 It is a brief description of an observed behavior that appears significant
for evaluation purposes.
 A factual record of an observation of a single, specific, significant
incident in the behavior of a patient.
 A verbal snapshot of an incident.
 A simple statement of an incident deemed by the observer to be
significant with respect to a given patient.
 The spot description of an incident, episode or occurrence i.e., observed
and recorded as being of possible significance.
 An objective description by the teacher of a significant occurrence or an
episode in the life of the patient.
 MEANING
 Informal device used by the nurse to record behavior of the students as
observed from time to time.
 It provides a lasting record of behavior which may be useful later in contributing
to a judgement about a patient.
 It gives useful information concerning an individual. The observer should be
objective and has to maintain various kinds of social relationships in which the
individual takes part.
 Nurses will note down the important happenings pertaining to a pupil for future
reference.
 The nurse describes the events he observed carefully and writes his comments,
takes the signature of the patient; he will also sign and keep it into the file, and
will be considered for evaluating the particular patient.
 Characteristics of anecdotal record
 A factual description of an event, how it occurred; what happened;
when it occurred and under what circumstances the behaviour
occurred will be described by the observer i.e., objective description of
patient’s behaviour recorded from time to time, along with observer’s
comments, the treatment.
 Each anecdotal record should contain a record of a single incident.
 Effective use of anecdotal records
 Specify the behaviour to be assessed in advance.
 Record enough of the situations to decrease subjectivity.
 Avoid too much dependency on memory by recording it time to time.
It increases its objectivity, validity and reliability.
 A single specific incident has to be recorded (positive and negative
aspects) and consider both in making inferences.
 Relates anecdotal records directly to the clinical objectives.
INCIDENT REPORT
 What Is an Incident Report?
 An incident report is an electronic or paper document that provides a
detailed, written account of the chain of events leading up to and following an
unforeseen circumstance in a healthcare setting. The incident doesn’t have to
have caused harm to a patient, employee, or visitor, but it’s classified as an
“incident” because it threatens patient safety.
 To ensure the details are as accurate as possible, incident reports should be
completed within 24 hours by whomever witnessed the incident. If the
incident wasn’t observed (e.g., a patient slipped, fell, and got up on his own),
then the first person who was notified should submit it. For the most part,
these incident reports are completed by nurses or other licensed personnel
and are used for risk management, quality assurance, educational, and legal
purposes.
 What’s the Purpose of an Incident Report?

Incident reports are used to communicate important safety information

to hospital administrators and keep them updated on aspects of patient
care for the following purposes:
 Risk management. Incident report data is used to identify and

eliminate potential risks necessary to prevent future mistakes. For

example, if an incident report review finds that most medical errors
occur during shift changes, risk management teams may suggest that
nursing staff develop standardized turnover protocols to avoid future
errors.
 Quality assurance. Quality assurance is all about patient safety,
customer satisfaction, and improving healthcare quality. Quality
control groups comb through incident reports to look for indicators
that suggest a patient received high-quality, patient-centered care at a
reasonable price.
 Educational tools. Incident reports make great training tools because
everyone has an innate ability to learn from their mistakes — or the
mistakes of others. Healthcare teams often use resolved incident
reports as educational tools to prevent similar occurrences.
Be aware that because incident reports could potentially be used for legal
purposes, providing incomplete, inaccurate, or false documentation in an
incident report can harm patients and jeopardize the defense of any case
— including your own.
What Classifies as an ‘Incident’ That Would Prompt a Report?

 Unexpected events related to prescribed medications and/or

treatments
 Examples: adverse reactions, equipment failure or misuse, medication errors
 Bodily injury
 Examples: assaults, burns, falls, needle sticks
 Patient-related occurrences
 Examples: complaints, elopement (i.e., the patient leaves without
authorization), treatment refusal
 Near misses
 Example: potential for an error existed but was corrected before it occurred
Consider the following examples as situations in which an incident report should
be filed:
 You’re working as a nurse on an acute inpatient psych unit when one of the
patients begins to act violently and attacks a staff member or another patient.
 You’re ambulating a patient in the hallway and securely holding onto their gait
belt when the patient abruptly falls to their knees before you had a chance to
react.
 You’re interviewing a clinic patient who passes out and falls from the
examination table onto the floor without warning. Upon awakening, the
patient appears to be fine but passes out again a few minutes later. Emergency
medical services are called to respond
 What Information Do You Put in an Incident Report?

 Date, time, and facility location

 Where the incident occurred
 Incident type
 Name of the person(s) affected by the incident
 Witnesses or names and titles of other involved persons
 Written summary of what happened, which can include:
 Detailed description of the event with events listed chronologically
 Witnesses or injured party statements
 Injuries sustained by the person(s) as a result of the incident or the outcome
 Actions taken immediately after the incident occurred
 Treatments administered
 Contributing factors
 Name(s) of who was notified (i.e., doctor, supervisor)
 Recommendations for change to prevent future incidents
 6 Tips for Writing an Effective Incident Report

 Tip #1: Make sure it is clear, concise, and accurate.

 Tip #2: Use proper grammar, punctuation, and spelling.
 Tip #3: State facts objectively and avoid making assumptions or
casting blame.
 For example:
 Write this: “The patient, who typically uses a cane, was walking down
the hall when he slipped on the wet floor. The patient was not using
his cane at the time of the fall.”
 Not this: “The patient was walking too fast down the hall and slipped.
He should have been using his cane.”
 Tip #4: Provide a chronological sequence of events.
 For example:

12:05, Rob from Environmental Services finished mopping the floor. A

“Caution: Slippery When Wet” sign was displayed.
12:15, Simon fell on the floor.
12:15, Nurses were called.
12:16, Charge nurse Mary arrived first and assessed the patient.
 Tip #5: Include direct quotations made by witnesses or the injured
party, if applicable.
 Provide full names of these witnesses in case they are needed later.
 Tip #6: Start the writing process early or take notes shortly after to
remember key details.
NURSING KARDEX

The Kardex is a tool that provides a holistic view of the

patient while communicating interdisciplinary and team
decisions that impact patient outcomes.
 What's in a Kardex?
 Chief Complaint
 Admit Day (you can calculate the length of stay)
 Allergies
 Nurse to Nurse Communication
 Diet Orders
 Critical, Current, or otherwise important Medications
 Lab draws and their frequency
 Other relevant orders like consults, etc.
 201 FILE
 An employee 201 file, usually containing records pertaining to the
employee’s personal information, employment contract, duties, salary,
performance and employment history, among others, is established
and maintained by an employer for specific purposes relating to the
employee’s employment, i.e. payroll, training and development,
performance evaluation, promotion, etc. As this file is compiled and in
part, created by and held under the custody of the company, such files
may be considered company property and acquiring a copy thereof
may still be governed by certain company rules and regulations.