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Sentinel Event Literature Review

Darby R. Floyd

Department of Nursing, Jacksonville State University

NU350: Professional Roles

Dr. Wendy Key

March 3, 2024
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Sentinel Event Literature Review

A nurse's job is to provide direct patient care and manage all patient needs within their

designated shift. When providing care to patients, all needs must be met in a timely manner.

However, patients often experience a delay in treatment. “A delay in treatment is when a patient

does not get a treatment that had been ordered for them in the time frame in which it was

supposed to be delivered” (The Joint Commission, 2021). Due to the frequency of occurrence,

The Joint Commission (2021) now identifies a delay in patient care as a sentinel event or “a

patient safety event that reaches a patient and results in death, permanent harm, or severe,

temporary harm and intervention required to sustain life.” There are multiple reasons for this

occurrence and potential remedies to prevent them. Reasons for occurrence may include

inadequate staffing, communication failure, improper planning, inadequate assessments, or

misdiagnosis. This literature review examines and identifies possible causes of delay in treatment

and prevention techniques to improve patient outcomes.

Two research studies analyzed the cause and effect of patient care and treatment delays.

These articles were chosen using the EBSCO database. The two research studies were conducted

between 2012 and 2019 and highlighted the relationship between missed or delayed nursing care

and adverse patient outcomes. An analysis was performed utilizing nursing staff, patients, and

electronic medical records. Systematic reviews and meta-analyses were omitted. The first article

was chosen after reviewing the content provided and after a thorough search on the impacts of

delayed treatment in patients. This article details delays in the treatment of symptomatic patients

while highlighting three classes of medications: antipyretics, inhalers, and vasodilators. The

second article was selected after reviewing the content on causes of missed or delayed nursing

care, showcasing the nurse’s rationale regarding the occurrence of adverse events.
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Both articles provide different viewpoints on the cause of delay in patient care and

treatment. Meng, et al. (2022) wrote an article discussing delayed treatment in symptomatic

intensive care unit (ICU) patients utilizing statistical data via electronic medical records (EMR).

These records were obtained between January 2012 and December 2015, analyzing 100 critical

care beds from four hospitals. Timestamp data was utilized as the primary focus for times

medications were ordered, drawn, and scanned for administration. These medications were

ordered on an as-needed basis with criteria for administration. Any medication delay was

identified as “the difference in minutes between the medication delivery time and the medication

order time” (Meng, et al., 2022).

Abdelhadi, et al. (2022) recruited nurses from diverse backgrounds to participate in a

qualitative study that focused on open discussions regarding workplace interference, how it

contributes to missed nursing care, identification of possible causes, and potential preventative

measures. Thirty-four nurses were interviewed, with results drawn from their individual

perspectives. Different methods were utilized to analyze and interpret the information gathered

from both articles. Utilization of the study completed by Abdelhadi, et al. (2022) should be

considered with caution due to the small population variable size of 34 nurses. However, the

analysis does provide a first-hand account of nurses who have experienced workplace

interruptions that have caused a delay in patient care. When reviewing data collected via Meng,

et al. (2022), questions may arise in regard to the validity of statistical significance due to

potential variables, such as outside influences, leading to a delay in patient care. However,

results were gathered by Meng, et al. (2022) over three years from 47,370 patients, with only

6,404 patients meeting the required criteria. This information was gathered from electronic
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medical records to ensure unbiased results and then further analyzed to ensure the criteria were

met to ensure accuracy (Meng, et al., 2022).

The articles highlighted risk factors associated with a delay in patient care. These risk

factors include delays in care due to nursing shift change, staffing shortages, multiple high-acuity

patients, system alarms, broken/insufficient equipment, computer system faults, and asynchrony

among coworkers and patient’s relatives. These workplace interruptions can cause a delay in care

and delay in the identification and treatment of acute complaints. Meng, et al., (2022) found that

delayed administration of antipyretics increased the likelihood of elevated patient body

temperature by 32.94%. It was also discovered that delaying a bronchodilator by 75 minutes

increases the odds of increased patient respiratory rate by 79.5% (Meng, et al., 2022). Lastly,

they discovered that a 45-minute delay in vasodilator administration increased the likelihood of

hypertension two hours post-medication order by 134% (Meng, et al., 2022). Abdelhadi, et al.

(2022) found that when faced with workplace interruptions, the likelihood of nurses postponing

tasks increases when there are multiple interruptions, prompting them to experience a loss of

perceived control of a situation.

Workplace interruptions occur more often than expected and can cause serious harm to

patients. Hospitals must ensure the daily availability of adequate staffing, resources, and

equipment to prevent delays in patient care. Such discrepancies may lead to a delay in patient

care, further compromising positive patient outcomes. As nurses, it is important further to

encourage research regarding causes of delayed patient care to reiterate the need for adequate

staffing and resources and encourage limited interruptions within the patient care setting.

Overall, the primary focus of positive nursing intervention should clinically correlate with

improved and positive patient outcomes.

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Citations

Abdelhadi, N., Drach-Zahavy, A., & Srulovici, E. (2022, January). Work interruptions and

…..missed nursing care: A necessary evil or an opportunity? the role of nurses’ sense of

…..controllability. Nursing open. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685781/

Meng, L., Laudanski, K., Restrepo, M., Huffenberger, A., & Terwiesch, C. (2022, January 10).

…..The Impact of Delayed Symptomatic Treatment Implementation in the Intensive Care Unit.

…..National Library of Medicine. Retrieved March 3, 2024, from

…..https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8774917/

Most commonly reviewed Sentinel event types. jointcomission.org. (2021, February 1).

…..https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/senti

…..nel-event/most-frequently-reviewed-event-types-2020.pdf