Healthcare Sentinel Events and Communication Barriers


The safety of patients and the healthcare providers is a vital element in the delivery of healthcare. It is the responsibility of the healthcare givers and administrators to ensure that measures are taken to prevent errors that can be detrimental to the patient and the risky practices that increase the potential to harm the patients and the care providers. According to the Institute of Medicine (2008), errors are ranked eighth in the causation of deaths in the United States of America. Various steps have been taken to reduce the sentinel events. However, the sentinel events still take place. It is worth noting that the events are not confined to some health facilities, but they can be anywhere due to systematic failures. The following paper presents a sentinel event, communication barriers in the event, and provides a root cause analysis.

Sentinel Event

The sentinel event took place in a health facility in the USA where the cases of nosocomial infections have been on the increase. The administration of the hospital came up with a safety policy that requires all workers to adhere to strict health measures to prevent infections. The employees have an obligation to wash their hands and out any other desired disinfection process before leaving a patient’s room. Dena, a registered nurse was in one of the nursing units where a patient suffering from an infectious disease was admitted. A doctor attended the patient and left without washing his hands and proceeded to another patient’s room. Dena was tired and did not tell the doctor to wash his hands in order to avoid possible infections and personal harm.

Barriers to Communication Identified in the Event

A patient’s safety is the freedom from accidental injury. Sorbello (2008) noted that the health of the patients can be enhanced by the establishment of operational systems that minimize the possibility of sentinel events. A simple communication to remind the doctor to wash his hands can prevent a great health problem. In the context, the organizational environment and status differences contributed to the communication barrier.

Role of a Nurse Administrator in Preventing Sentinel Events

According to Aust (2007), sentinel events result from systematic failures. The failures may occur due to poor communication among employees, as well as organizational and structural barriers. Quigley and White (2013) noted that one way to avoid cases of sentinel events is to ensure that there is a healing environment in the hospital. Therefore, the role of a nurse administrator in preventing sentinel events is to treat an event as a set of concentric circles instead of treating it as an individual mistake. The framework of the concentric circle places the patient in the innermost circle while the care providers are placed at the outermost cycle. This approach ensures that the nurse administrator deals with the event by diagnosing the work environment and hence devising a systematic solution. Chen, Tzeng, Cheng and Lin (2012) noted that systematic solutions prevent future mistakes and avoid victimization of individuals. In the context of the sentinel event, the nurse administrator should improve the work environment in the nursing units and initiate strategies that uphold delivery of quality care to patients.

Root Cause Analysis

In this case, the root cause analysis helps in the identification of the factors that contributed to a sentinel event. The root cause analysis focuses on the processes and the systems rather than on individual actions. The approach entails finding why the event took place, the possible circumstances that led to it and improvements that can be made to avoid a repeat of the event (Sorbello, 2008). The identified sentinel event predisposed the other patients to a higher risk of infections. In case of the infections, the administration of the hospital can easily blame the doctor and the nurse for facilitating the occurrence of the sentinel event. However, an in-depth analysis shows the interplay of many factors. For example, the hospital had not put in place notifications to remind the doctors about the hospital policy. The administration could have set a simple alert system in all patients’ rooms to remind the doctors to wash hands before leaving the room.

The other cause is related to social status differences. The management has no effective strategic human resource practices that promote an environment of teamwork. Due to the work environment, the registered nurse was tired and thus did not remind the doctor to clean his hands. Secondly, she was afraid to approach the doctor; this happened due to the status differences among the healthcare providers. Status differences discourage teamwork, which leads to disjointed healthcare delivery. Besides, the administrators should ensure that all the healthcare providers are empowered through a good work environment. For example, the administration must develop a flexible work program to avoid overworking the healthcare providers.


Based on the root cause analysis, systematic and management issues were found to have contributed to the sentinel event. Also, the paper has shown the importance of creating hospital healing environments which contribute in reducing sentinel events. Administrators of health facilities need to put in place strategic measures in order to avoid repeat errors. Thus, solutions to sentinel events should not be treated as individual mistakes; instead, a review of the health system should be undertaken to identify factors contributing to the errors.


Aust, M. (2007). Front line of defense: The role of nurses in preventing sentinel events. Journal of High Acuity, Progressive, and Critical Care Nursing, 27(6), 1-5.

Ballard, K. A. (2003). Patient safety: A shared responsibility. Journal of Issues in Nursing, 8(3), 4-11.

Chen, Y. L., Tzeng, D. S., Cheng, T. S., & Lin, C. H. (2012). Sentinel events and predictors of suicide among inpatients at psychiatric hospitals. Annals of General Psychiatry, 11(1), 1-6.

Institute of Medicine. (2008). To err is human: Building a safer health system. Washington, DC: National Academy Press.

Quigley, P., & White, S. (2013). Hospital-based fall program measurement and improvement in high reliability organizations. The Journal of Issues in Nursing, 18(2), 1-7.

Sorbello, B. (2008). Responding to a sentinel event. Web.

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