Running Head: SENTINEL EVENT

Sentinel Event Related to Behaviors that Undermine Culture of Safety

Tayler Lamagna
California State University, Stanislaus
December 15, 2014

SENTINEL EVENT
Sentinel Event Related to Behaviors that Undermine Culture of Safety
Considered one of the best moments for any mother, giving labor is truly an amazing
experience. But for Laura, the experience was the total opposite. After being in labor for
almost two days, her baby didnt make it out into the world. Lauras unborn baby died after
failure by the Registered Nurse (RN) to report an abnormal fetal monitoring strip to the
attending physician (AP). In this situation, the RN wanted to use her clinical judgment, but
was intimidated by the doctor's past reputation of becoming angry with staff. While the
correct monitoring was being implemented on this patient, appropriate communication
between the RN and the AP could have ultimately saved this babys life. Eliminating
intimidating behaviors within the hospital can prevent serious injury or death to
patients. The sudden death of Lauras unborn baby was a horrifying event for both her and
her family.
Laura went into labor at 39 weeks gestation to deliver a full term, healthy baby boy.
As her family gathered in the delivery room, their anticipation and excitement turned to
terror as the RN came running in the room. The RN noticed abnormal readings from the
continuous fetal monitor that indicated a life threatening emergency to Lauras baby, but
failed to notify the AP. According to Lowdermilk, et al. (2012), nurses should notify the
physician or nurse-midwife immediately and initiate appropriate treatment of abnormal
patterns when they see a prolonged deceleration (p. 425). Laura most likely required an
emergency cesarean section to save the babys life. But because she did not notify the AP,
Lauras baby died. Because the death of this fetus was caused by ineffective communication
due to intimidating behaviors within the hospital, The Joint Commission (TJC) aggregates a
Sentinel Event.

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Sentinel Event

A sentinel event is an unexpected incident that ultimately results in death or serious

injury including both physical and psychological (TJC, 2013). This also includes events that,
if repeated, are at risk for causing death or serious injury. Loss of a limb or function is
included in serious injuries. Examples of sentinel events include: suicide of a patient 72
hours or less after discharge, surgery on the wrong patient or wrong site, and unanticipated
death of a full-term infant (TJC, 2013). Such events require immediate response and change
to prevent a reoccurrence from happening in the future. The goal of TJC is to improve safe
patient care while reducing the number of sentinel events that occur (TJC, 2013). TJC
provides a protocol that healthcare facilities can use to identify and respond to such events.
The protocol includes performing a root cause analysis, developing an action plan,
implementing the action plan, and evaluating the response to the plan (TJC, 2013).
Sentinel event alert 40, behaviors that undermine a culture of safety, specifically
addresses this nurse and doctor relationship that can negatively affect patient outcome.
Disruptive behaviors are not limited to physicians, but seem to have the biggest impact on the
healthcare team and patient outcome (Porto and Lauve, 2006). Intimidation in the workplace
is not uncommon. Based on a survey on intimidation in the workplace by Institute for Safe
Medication Practices (2003), 28 percent of RNs reported physicians using condescending
language towards them and 20 percent reported physicians who often refused to answer their
questions. Lauras RN was afraid to call the AP because of prior negative experiences with
him. In the past, whenever the RN called the AP with a question or concern, he would get
angry and treat her with disrespect. Lauras RN was not alone, as a mere 49 percent of RNs
reported that past negative experiences with APs had altered the way they handled situations

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that required clarification by the AP (ISMP, 2003). Doctors using intimidating behaviors in
the workplace can reduce the extent to which nurses are willing to exercise their rights (PME,
2010). Physicians are expected to work collaboratively within their health care team to
promote safety and efficiency (PSO, 2008). In the matter of a sentinel event, it is
recommended that a root cause analysis (RCA) be done by the institution in order to find the
cause and to prevent any reoccurrences.
Root Cause Analysis
An RCA allows staff members, of the institute where the sentinel event took place, to
look at the in-depth cause. It primarily focuses not on the staff members, themselves, but on
systems and processes (TJC, 2013). The goal is to identify what went wrong in the
institutions specific system in order to correct it and prevent or decrease the likelihood of
additional events. The individuals who were involved in the sentinel event, as well as
hospital administration, should identify the cause by asking a series of why? questions. By
doing so, potential and actual causes are identified. This, then, leads to the identification of
the root cause that the team can take action against. An RCA should include categories that
are further explored: policy and procedure, people, environment, and technology. Appendix A
shows a fishbone diagram of the root cause analysis related to this sentinel event.
Policy and Procedure
Policies and procedures are used within hospital facilities to provide health care
workers a step-by-step guide for completing tasks. It is important to have clear and concise
policies to ensure adequate patient care and reduce errors. In regards to labor and delivery,
standard FHR monitoring should be assessed and documented every 15 to 30 minutes during
active labor (NNEPQ, 2012). When there are abnormal fetal readings, initiation and

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documentation of nursing intervention, FHR, uterine activity and response to interventions is

required. Consultation with the patients care provider, with appropriate documentation, is
also required with abnormal readings (NNEPQ, 2012). In Lauras case, her RN was required
to consult the AP with the abnormal results to obtain the necessary interventions required to
save her unborn babys life. The RN did not notify the AP because of fear from past
intimidating negative experiences with this AP. Instead, she performed nursing interventions
in order to try and correct the abnormal fetal readings herself, avoiding any interaction with
the AP.
People
Nurses, doctors, patients and patients family members are all included in
intimidating behaviors within the hospital. The nurse and doctor relationship should be
collaborative in order to prevent errors. According to Physicians and Surgeons of Ontario
(2008), As professionals, physicians are expected to act in a courteous, dignified and civil
manner towards their patients, their colleagues and others involved in the provision of health
care (p. 2). But in reality, physicians may act unprofessionally due to poor role models,
forming bad habits. Working in a stressful environment with high demands and high patient
loads may also contribute to disruptive physician behaviors (PSO, 2008). This is not a rare
occurrence within the hospital; more than 95 percent of nurses reported encountering
disruptive or dangerous behaviors on a regular basis, most often occurring between a
physician and a nurse (Weber, 2004).
Environment
The environment in the workplace greatly contributes to the effectiveness of
relationships within the hospital. Organizations that ignore disruptive behaviors are indirectly

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promoting it (Hickson, 2007). It is important to identify the unacceptable behaviors, address

them, and prevent the behavior from happening again to promote a healthy working
environment. A healthy work environment values all healthcare team members opinions
regarding a patients plan of care and eliminates the fear associated with reporting errors to
those who hold authority (Porto & Lauve, 2006). A non-punitive environment is needed, to
focus on the importance of reporting and correcting disrupting clinician behaviors. Stress in
the clinical environment is likely a contributing factor to disruptive behavior. Stress is often
attributed to a shortage of nursing staff with high workloads. In addition, the patient safety
movement has shifted the prior captain of the ship attitude towards physicians to a more
team-based approach. Because of this, the more seasoned physicians are frustrated with their
loss of power, which may contribute to disruptive behavior towards nurses (Porto & Lauve,
2006). Increased pressure due to increased governmental oversight, intrusive managed care
regulations, and greater liability risks have also been cited as factors that contribute to
disruptive behaviors as well (Rosenstein & O'Daniel, 2005).
Technology
Electronic fetal heart rate (FHR) monitors are used to track the FHR while the mother
is in labor. The FHR patterns seen when using a fetal monitor may indicate fetal well-being
and fetal oxygenation (NNEPQ, 2012). The nurse is required to contact the physician if he or
she witnesses an abnormal FHR on the monitor. The physician is then responsible for
deciding the needed intervention with the best outcome for the fetus and the mother. The
problem, then, lies in the interpretation of the FHR monitors. What one nurse classifies as life
threatening, another nurse can disregard the reading all together. There is no consistent way

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in interpreting the FHR readings (King & Parer, 2011). Even if there is suspicion of an
abnormal FHR, the physician should be notified for further instruction.
Change Theory and Action Plan
After analyzing the root cause analysis, an action plan is formulated to identify the
strategies the organization intends to act upon, in order to reduce sentinel events from
occurring in the future (TJC, 2013). Change theories are used to initiate the action plans after
a sentinel event. Kurt Lewins 3 step change theory will be utilized as a tool to create an
action plan in the hospital setting. The steps of the Lewin change theory consist of
unfreezing, moving, and refreezing (Burns, 2004). The goal of the action plan is to create a
safe working environment between all hospital staff, to decrease the likelihood of a
reoccurring sentinel event, in order to ensure patient safety.
Unfreezing
The first step to change is persuading the organization that change is needed (Burns,
2004). Unfreezing allows the hospital staff to understand why change is necessary. Change
will not happen until the status quo is considered ineffective. That being said, old practices
need to be abandoned before new practices can be developed. Qualitative evidence is an
effective way of showing the employees within the organization that unfreezing is necessary
(Mind Tools, 2013). Staff members should complete a self-assessment in order to understand
that change is needed (Rosenstein & O'Daniel, 2005). This will increase self-awareness of
any underlying barriers or resistance before moving on. The number of sentinel events due to
disruptive behaviors between staff members within the hospital could also be used as
evidence. Lewin argued that . . . unless sufficient psychological safety is created, the
disconfirming information will be denied or in other ways defended against, no survival

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anxiety will be felt. and consequently, no change will take place (Schein, 1996, p. 61). In
other words, the staff needs to feel safe in order to accept change, as well as be willing to
modify current practice (Burns, 2004).
Moving
As the equilibrium of a system is destabilized and old practice has been demonstrated
to be ineffective, the change stage, or the moving stage begins (Burnes, 2004). Moving is
essentially when change starts to happen, and when change becomes permanent. Staff slowly
embrace the change and start thinking of ways to do so (Mind Tools, 2013). They need to be
motivated and convinced that they will benefit from such change. Unfortunately, some are
harmed from change, but those tend to be the people who were benefiting from the status
quo, which has endangered patients. Others will still be susceptible to change, and it is the
action plans job to manage this behavior. Time and communication are key elements to the
moving step. Staff may require hands-on learning in order to understand the changes fully.
People need to feel connected to the organization, and through time, will succeed through the
transition phase (Mind Tools, 2013). In preventing other sentinel events, related to disruptive
behavior in the workplace, a few changes must be made.
A universal code of conduct should be implemented within hospital organizations in
order to better define and identity disruptive behaviors (Rosenstein & O'Daniel, 2005; Porto
& Lauve, 2006). By having a code, there will be more clarification as to what is deemed
unacceptable behavior and leave less room for argumentation. It should be identical for all
hospital staff, physicians, patients as well as patients family members. The code should
include policies, procedures, and regulations to serve as grounds for violators and dismissals.
It should be updated by fellow employees including nurses, physicians, pharmacists, and

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other staff members. This code of conduct should be implicated within the hospital and serve
as guidance for all staff members. All staff members should be provided a copy of the code,
along with education on appropriate behaviors, as well as training on how to handle
inappropriate behaviors (Rosenstein & O'Daniel, 2005; Porto & Lauve, 2006). Training
should include what to do in the event that he or she witnesses behavior that violates the
code. After training, each staff member should be required to sign a statement saying they
will comply with the code of conduct which includes consequences of not complying.
Consequences of failing to comply with the code of conduct may result in termination of
privileges or even employment. This statement should then be resigned annually to
communicate the importance of the code (Porto & Lauve, 2006).
Along with a well-developed code of conduct, organizations must have a plan in
order to measure the compliance of the code (Porto & Lauve, 2006). This not only includes
voluntary reporting but requires the hospital to rigorously evaluate independently. This can
be done by regular staff surveys, team member evaluations, and rounding with direct
observation (Porto & Lauve, 2006). Hospital leaders should be properly trained on how to
monitor and evaluate compliance with the code of conduct. Since most disruptive behavior
goes unreported due to fear, there will not be as many voluntarily reports within the hospital
(Rosenstein & O'Daniel, 2005). Therefore, hospitals need to monitor, independently as well
as voluntarily, for disruptive behaviors, before a patient injury or a sentinel event occurs.
Physicians and nurses view disruptive behavior policies as ineffective because they
are rarely enforced (Rosenstein & O'Daniel, 2005). Hospitals must overcome this negative
outlook on disruptive behavior policies by consistently responding to violations in a timely
manner (Porto & Lauve, 2006). Physicians and nurses should be screened for excessive

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stress, illness, and lack of knowledge. These identified factors should not be presumed to
exist as an excuse for violation, especially for intimidating physician behavior. Each violation
of conduct should be documented by identifying the severity, presence of identifiable factors,
as well as the risk to harm patients. Every team member involved should be independently
interviewed by a nurse manager, especially the violator. Necessary steps are identified in
order to address the violators actions. This should be consistent for all hospital staff in that
the violator will be removed from the environment immediately if a patient is in danger. This
not only means quick discipline with violations, but withhold of discipline when there are no
violations. Every staff member must be treated equally with this approach in order to
accurately accomplish a culture of safety (Porto & Lauve, 2006).
Refreeze
When the new changes are taking shape, and the people are
embracing the new ways of handling disruptive behaviors, the
organization is ready to refreeze. The refreeze step is the time period
where changes made in the moving step become the norm in the culture
of the unit. Stability must be rebuilt into the organization as people
reorient themselves within the changed environment. A sense of
community and involvement develops with the celebration of new
successes within the workplace (Mind Tools, 2013).
An oversight committee, run by someone who is willing to take responsibility for
transforming the institutes culture, will be responsible for enforcing the disruptive behavior
policy to ensure patient safety (Porto & Lauve, 2006; Rosenstein & O'Daniel, 2005). This
committee will be responsible for recognizing violation patterns and come up with solutions

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to fix these violations. The oversight committee will survey the hospital staff once a month to
see how effective the current policy is. Based on the results of these surveys, the oversight
committee will then create topics for educational courses the staff members have an option to
attend. Topics might include teamwork, collaboration, effective communication, mutual
respect, anger management, as well as phone etiquette for dealing with physicians on the
phone (Rosenstein & O'Daniel, 2005). Once there is a 50 percent improvement satisfaction
with the new code of conduct, surveys will be given once every six months. A goal of zero
tolerance for any disruptive behaviors within the health care team will be rewarded. It is
important that staff members are encouraged to participate in changes, not by a culture of
punishment, but rather a self-reporting of events to ensure patient safety. Appendix B
outlines the budget required to accomplish this action plan.
Targeted Population and Stakeholders
The targeted stakeholders affected by this change include nurses, physicians, other
staff members, patients, and patients families. While disruptive behavior can be seen by any
hospital staff, problems are most often caused by doctors, perhaps because institutions have
treated doctors differently in the past and there seems to be a tolerance to this (Wyatt, 2013).
All hospital staff members will be affected, through the change in protocol and new code of
conduct, to ensure a culture of safety. It has been reported that 68 percent of nurses report
that adverse events are a result of disruptive behaviors in the hospital and 73 percent of
nurses feel it leads to errors (Rosenstein & O'Daniel, 2005). But sadly, most of these nurses
and physicians feel disruptive behavior policies are rarely enforced. At first, staff might be
reluctant to implement a new policy that they lack faith in. Providing them with evidencebased research regarding why each change is important, and how it will improve

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relationships within the hospital, may be effective in changing their current perceptions.
Nurse and physician interaction will now be dictated by new protocol and hopefully improve
over time. Patients and their families are stakeholders in this change because the quality of
their care will now be directly improved with better teamwork and collaboration between
health care staff.
Conclusion
Sentinel events involving a culture of safety in the workplace affect many people,
patients being the most important. When these sentinel events do occur, it is important to do a
root cause analysis and develop an action plan to better prevent another from happening in
the future. With the work of all hospital staff involved, future errors within the health care
settings will not happen again due to intimidating behaviors. With an effective modification
of policy and procedure, and the combination of evidence-based safety for patients, future
sentinel events, involving a culture of safety within the workplace, will be prevented.

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