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The Joint Commission defines a sentinel event as follows:

“A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response.”

Study the following case, which involves a sentinel even. In a 1-page Word document, write your answer to the case study question that follows. (Any citations should be in APA format.)

Johnny’s Fatal Overdose

After a visit to his pediatrician, two-year-old Johnny Solerno, who suffers from a chronic kidney condition, was admitted to Community Hospital for control of high blood pressure. While being treated at the hospital, Johnny received a massive overdose of a drug used to lower his blood pressure, resulting in deprivation of oxygen to the brain and permanent brain damage. The drug in question comes in adult strength only and must be diluted in the hospital pharmacy before syringes are prepared for pediatric use. The pharmacy technician labeled the drug as diluted, yet failed to dilute it. The supervising pharmacist did not catch the error, causing the child to receive an adult strength dose of the drug.

 

Case Study Question

What steps should Community Hospital take to prevent such a sentinel event from happening in the future?

In your answer, follow the steps suggested by the Joint Commission in this article:

Explain how each of these steps can be effective in preventing this type of fatal error. Use APA format for any citations.

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