A sentinel event is characterized by an unforeseen incident that leads to severe physical or psychological harm or death, which is unrelated to the patient’s initial condition. Such occurrences profoundly impact not only patients and their families but also healthcare providers and institutional credibility. Analyzing these events is vital to uncover systemic vulnerabilities and implement necessary safeguards to mitigate future risks.

In the scenario under review, a sentinel event took place in the Emergency Department (ED) due to a communication failure during a staff handoff. A patient with sepsis experienced a delay in receiving critical care because vital information was omitted during the shift change. This miscommunication led to the patient’s worsening condition, requiring extended hospitalization and complex interventions. The event caused emotional turmoil for the family and imposed additional pressure on the clinical team, potentially affecting their morale and reputation.

Upon thorough investigation, multiple contributing factors were uncovered. Fatigue and excessive workloads impaired the outgoing nurse’s ability to convey essential information. A lack of standardized communication methods, such as SBAR (Situation, Background, Assessment, Recommendation), and insufficient documentation practices further compounded the problem. Additionally, the facility lacked a proactive safety culture and effective leadership. Diverse communication styles across staff members, environmental obstacles like faulty equipment and poorly designed workspaces, and inconsistent policy enforcement also played critical roles.

Breakdown of Factors and Root Causes

A deeper analysis of the sentinel event revealed shortcomings across various operational and individual domains. The SBAR protocol, although available, was inconsistently applied. The outgoing nurse failed to conduct a comprehensive bedside handoff or verify care plans. Meanwhile, the incoming nurse did not seek additional details, presuming the handoff was complete. Vital sign monitoring was inadequate, and alarms often went unnoticed due to desensitization—a common issue known as alarm fatigue.

Personnel involved included two nurses and a physician. The physician’s medication instructions were not accurately communicated, and leadership failed to ensure staff adhered to protocols or received adequate training. Policy documents were either outdated or difficult to locate, causing confusion and inconsistency. Additional challenges included distant nurse stations, defective equipment, and limited access to ongoing education on emergency response procedures. These findings collectively point to a broader organizational lapse in reinforcing safety protocols and maintaining operational efficiency.

Strategies for Improvement and Preventive Measures

To avert future occurrences of similar events, a comprehensive strategy involving system-wide enhancements and adherence to best practices is essential. First, implementing and mandating the use of SBAR as a standardized communication framework can significantly improve information transfer during shift transitions. Research conducted by Mulfiyanti and Satriana (2022) supports the effectiveness of SBAR in elevating handoff quality and healthcare outcomes.

Additionally, ongoing simulation training should be instituted to prepare staff for emergency scenarios, improving their competence and confidence. Addressing alarm fatigue requires implementing intelligent alarm systems that prioritize critical alerts. Regular audits and the introduction of fail-safe protocols—such as automated alerts for abnormal vital signs—can facilitate timely clinical responses.

Further, the organization should offer regular refresher courses focusing on communication techniques and emergency procedures. Promoting a transparent, blame-free reporting culture is crucial for fostering continuous learning. This encourages staff to report near-misses and adverse events, thereby contributing to systemic improvements and enhanced patient safety.

Tabular Summary of Root Causes and Contributing Factors

Root Cause / Contributing Factor	Category	Code
Ineffective communication during handoff	Human Factor – Communication	HF-C
Lack of training on protocols and safety tools	Human Factor – Training	HF-T
Equipment malfunction delaying clinical response	Environment / Equipment	E
Staff fatigue due to poor staffing and workload	Human Factor – Fatigue/Scheduling	HF-F/S
Non-adherence to established procedures	Rules / Policies / Procedures	R
Organizational issues hindering teamwork	Barriers	B

Evidence-Based Strategy Table

Strategy	Objective	Supporting Evidence
SBAR Handoff Protocol	Ensure consistent and effective communication	Mulfiyanti & Satriana, 2022
Simulation-Based Emergency Training	Enhance clinical response in critical situations	Mulfiyanti & Satriana, 2022; AHRQ, 2020
Alarm Management Systems	Mitigate alarm fatigue and ensure timely interventions	AHRQ, 2020
Continuous Education and Refresher Courses	Keep staff updated on clinical and safety procedures	World Health Organization, 2021
Transparent Reporting Culture	Promote safe reporting without fear of repercussions	The Joint Commission, 2019

References

Agency for Healthcare Research and Quality. (2020). TeamSTEPPS®: Strategies and tools to enhance performance and patient safety. https://www.ahrq.gov/teamstepps/index.html

Mulfiyanti, R., & Satriana, I. W. (2022). The effect of SBAR communication on handoff quality at Tabanan Hospital. Griyatama Nursing Journal, 12(3), 150–156.