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Hi Ugochi
You have extensively analyzed the critical system and individual factors contributing to

sentinel events in emergency rooms. It is vital to add that other system-related factors may

include overcrowding due to uninsured patients and understaffing, leading to prolonged wait

times and compromised patient care. Inadequate funding further exacerbates these issues.

Ensuring adequate staffing, utilizing contract providers, and securing sufficient funding are

essential to address these system-related challenges. Individual factors, particularly the

responsibility of nurses and clinicians, play an essential role in patient outcomes. Missing critical

assessments, such as lactic acid levels, can have horrible consequences. To mitigate such errors,

improved communication and patient education are crucial (Elshayib & Pawola, 2020). Ensuring

patients and families understand discharge instructions and medication regimens is also vital.

Additionally, implementing strategies like hand hygiene policies and inter-professional discharge

plans can significantly reduce preventable errors and improve patient safety.
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References

Elshayib, M., & Pawola, L. (2020). Computerized provider order entry–related medication errors

among hospitalized patients: An integrative review. Health Informatics Journal, 26(4),

2834-2859. https://doi.org/10.1177/1460458220941750