Which scenario should be reviewed as a sentinel event by the committee?

Which scenario should be reviewed as a sentinel event by the committee?

• A. Hemolytic transfusion reaction due to major blood group incompatibilities
• B. A patient missing a medication
• C. A staff member slip and fall
• D. A patient refusing care

Answer: (B)

Sentinel events are unexpected occurrences that result in death or serious physical or psychological injury, or have the potential to do so, and they trigger formal review to identify system-wide fixes. A patient missing a medication points to a breakdown in the medication-use system—how orders are communicated, stocked, administered, and documented. This kind of omission can lead to harm if not addressed, so it clearly signals a safety vulnerability that the committee should investigate and correct through root-cause analysis and process improvements (like better dosing reminders, bar-code verification, or standardized administration protocols). The other scenarios involve different types of incidents or broader questions about consent and safety, but they don’t as directly reveal a systemic med-use failure that the sentinel-event review process targets.

Sentinel events are unexpected occurrences that result in death or serious physical or psychological injury, or have the potential to do so, and they trigger formal review to identify system-wide fixes. A patient missing a medication points to a breakdown in the medication-use system—how orders are communicated, stocked, administered, and documented. This kind of omission can lead to harm if not addressed, so it clearly signals a safety vulnerability that the committee should investigate and correct through root-cause analysis and process improvements (like better dosing reminders, bar-code verification, or standardized administration protocols). The other scenarios involve different types of incidents or broader questions about consent and safety, but they don’t as directly reveal a systemic med-use failure that the sentinel-event review process targets.