Sentinel events are unexpected incidents in clinical settings that result in significant patient harm, not attributable to the patient’s underlying medical condition. These occurrences can cause considerable distress for patients, families, and healthcare providers, while also undermining institutional integrity. The main goal of evaluating such events is to identify both surface-level and underlying issues to strengthen safety protocols and reduce recurrence.

In this scenario, a sentinel event occurred in the Emergency Department (ED) due to ineffective communication during a shift change. A patient with sepsis experienced clinical deterioration after the nurse handing off care failed to convey critical medical information. Coupled with inadequate documentation, this communication lapse delayed essential treatments, extending hospitalization and requiring more intensive interventions. The patient’s health worsened, their family experienced increased stress, and hospital staff faced reputational and operational pressures.

Analysis of Root Causes

Human Factors

Nursing staff were impacted by excessive workloads, limited staffing, and a lack of training in structured communication tools such as SBAR (Situation, Background, Assessment, Recommendation). The outgoing nurse, operating under stress, delivered an incomplete verbal report, contributing to critical omissions.

Systemic Inefficiencies

The absence of digital handoff tools, understaffed shifts, and a chaotic ED environment hindered effective patient care transitions. These structural deficits disrupted communication flow and care continuity.

Organizational Culture

Limited leadership engagement, poor enforcement of communication protocols, and an underdeveloped culture of accountability all contributed to unsafe practices. Supervisory personnel did not adequately monitor or reinforce adherence to standardized procedures.

Cultural and Language Barriers

Variations in language proficiency and cultural norms among staff may have resulted in misunderstandings and communication breakdowns during the handoff, further compromising patient safety.

Deviation from Protocol and Documentation Gaps

Investigations showed that the handoff did not follow the SBAR protocol. The report lacked structured verification, and essential patient details were omitted. Additionally, bedside handoffs were skipped, and clinical documentation failed to reflect vital updates, contributing to missed treatments and medication errors.

Leadership and Staff Involvement

The primary personnel involved were the outgoing and incoming nurses, along with a physician whose orders were not relayed properly. Supervisory staff, including the charge nurse, failed to ensure compliance with communication protocols, leading to oversight and a lack of accountability.

Communication and Environmental Challenges

There were significant breakdowns in interdisciplinary communication, particularly with regard to new medication orders. Physical barriers such as the location of nursing stations and faulty equipment impeded timely information sharing. Inadequate staffing further strained compliance with care protocols.

Policy and Monitoring Gaps

Policies regarding handoffs were either unclear or difficult to access. Staff reported confusion about the most current procedures, contributing to inconsistent care. Moreover, patient monitoring was inconsistent, and alarm fatigue led to missed critical alerts, worsening the patient’s condition.

Table 1: Root Causes and Contributing Factors

Root Cause/Contributing Factor	Category Code	Description
Incomplete handoff communication	HF-C	Lack of structured tools like SBAR led to missing clinical details.
Insufficient training on current protocols	HF-T	Staff lacked updated knowledge needed during patient transitions.
Staff exhaustion and poor scheduling	HF-F/S	Fatigue impaired clinical judgment and vigilance.
Non-adherence to SBAR protocol	R	Policy breaches caused inconsistencies in information sharing.
Equipment malfunction	E	Faulty monitors delayed critical response times.
Weak leadership enforcement	B	Inadequate oversight allowed procedural lapses to persist.

Legend: HF-C = Human Factor–Communication; HF-T = Human Factor–Training; HF-F/S = Human Factor–Fatigue/Scheduling; E = Environment/Equipment; R = Rules/Policies/Procedures; B = Barriers

Evidence-Based Approaches for Risk Mitigation

Research underscores the value of structured communication models in preventing clinical mishaps. A study at Tabanan Hospital found that SBAR implementation greatly enhanced communication effectiveness and patient safety outcomes (Mulfiyanti & Satriana, 2022). In addition, regular simulation drills and alarm response training can help mitigate risks associated with desensitization to frequent equipment alerts. Alarm fatigue, linked to up to 99% of false alarms, can lead to critical signals being overlooked (Shaoru et al., 2023).

Implementing frameworks such as Plan-Do-Study-Act (PDSA) cycles, safety audits, and real-time feedback loops can foster a culture of continuous improvement. Investing in staff education, updating technological systems, and promoting transparent leadership engagement are essential components of a sustainable patient safety strategy.

Safety Improvement Plan

Preventive Strategies and Interventions

To address the root causes identified, several proactive interventions are planned. Emphasis will be placed on standardizing communication during handoffs through mandated use of SBAR. Comprehensive training programs will be rolled out to improve staff competency in emergency procedures and equipment handling. Alarm fatigue will be tackled through technology audits to filter unnecessary alerts and improve responsiveness to priority signals.

Table 2: Safety Improvement Action Plan

Root Cause/Contributing Factor	Planned Intervention	E / C / A
Communication Errors	Mandate structured handoff protocols using SBAR.	E
Training Deficiencies	Initiate onboarding and quarterly refresher courses on safety procedures.	E / C
Alarm Fatigue	Reconfigure alarm systems to highlight critical alerts and reduce overload.	E

Key: E = Eliminate; C = Control; A = Accept

Policy and Professional Development Reforms

New Process Standards and Staff Education

To resolve system-wide issues, structured protocols such as SBAR will be integrated into all patient handoffs. Orientation for new staff will focus on competency in communication tools, equipment usage, and emergency response. Refresher sessions will be scheduled regularly. Furthermore, all alarm systems will undergo a comprehensive review to adjust thresholds and improve prioritization of alerts. These steps aim to build a culture centered on patient safety and evidence-based care.

Implementation Timeline and Anticipated Outcomes

Projected Results and Milestones

The improvement plan aims to lower the incidence of sentinel events, enhance care consistency, and build staff confidence. Better communication, reinforced competencies, and smarter alarm systems will collectively support safer clinical practices.

Table 3: Implementation Timeline

Intervention	Goal	Timeline
Standardized SBAR Implementation	Ensure consistent, thorough communication at handoffs	Within 1–2 months
Staff Training Programs	Strengthen clinical skills and protocol adherence	Initiate in 3 months; ongoing quarterly
Alarm System Optimization	Minimize alarm fatigue and boost response to critical alerts	Begin by month 3–4; complete by month 6

Observable improvements in safety outcomes and workflow efficiency are expected within 6 to 12 months of program execution.

Organizational Resources

Current and Required Resources

Available Assets To facilitate successful implementation, the organization will leverage several internal resources:

Skilled Personnel: Seasoned staff will mentor and lead protocol adoption.
Digital Infrastructure: Existing EHR systems will be updated to integrate handoff tools.
Established Policies: Current safety protocols will be revised and expanded.
Interdisciplinary Collaboration: Enhanced coordination among departments (nursing, pharmacy, IT) will support the rollout.

Additional Resources Needed To fill remaining gaps:

Training Modules: Custom SBAR and alarm management programs will be developed.
Technological Upgrades: Procurement of advanced monitoring systems is essential.
Data Analytics Tools: Monitoring platforms will assess progress and ensure continuous improvement.

References

Argyropoulos, C. D., Obasi, I. C., Akinwande, D. V., & Ile, C. M. (2024). The impact of interventions on health, safety and environment in the process industry. Heliyon, 10(1), e23604–e23604. https://www.sciencedirect.com/science/article/pii/S2405844023108127

Mulfiyanti, D., & Satriana, A. (2022). The correlation between the use of the SBAR effective communication method and the handover implementation of nurses on patient safety. International Journal of Public Health Excellence (IJPHE), 2(1), 376–380. https://doi.org/10.55299/ijphe.v2i1.275