Factors affecting sentinel events in hospital emergency department: a qualitative study

Abstract

Purpose A sentinel event is an unexpected occurrence resulting in death or serious physical or psychological injury or the risk thereof. The purpose of this paper is to investigate the influencing factors of sentinel events in the emergency department of a military hospital in Tehran to find out some of the effective solutions. Design/methodology/approach In this qualitative study with content analysis approach, 20 hospital healthcare personnel participated as participants from the fields of medicine and nursing. Purposive random sampling and semi-structured interviews were used for data collection. Atlas.ti software version 5.2 was used for data analysis. Findings Four themes and 32 subthemes were identified by numerous revisions and combining the codes. The four main themes of sentinel events were: causes, incidence barriers, cause prevention solutions, and barriers' improvement solutions. Moreover, these main factors were related to these issues: staff and patients' education, communication, assessment, patients and their companions, employee rights, leadership, care continuum, human factors, physical environment, information management and medication use. Some solutions were also suggested according to these factors and a policy was recommended. Practical implications Hospital managers and authorities should try to find the main causes of sentinel events by periodical analysis to find ways to prevent them in the future, using logical and reasonable solutions. Originality/value This study confirms that strategies to reduce the sentinel events in emergency departments should focus on empowerment of all staff.

Explaining challenges of obstetric triage structure: A qualitative study

“…The documents have shown that the use of the ESI triage system and the division of work shifts per day will lead to improved job potential and increased satisfaction of clients (Tatli et al, 2018). Studies have indicated that lack of human resources, lack of expert human resources and absence of basic rules are some of the important factors in the development of events in the emergency department (Zaboli, Malmoon, Soltani‐Zarandi, & Hassani, 2018). The results proved that some of the main causes of unwanted incidents in the emergency room are the lack of timely access to individuals and professionals, unavailability of up‐to‐date and appropriate instructions, the absence of a team aware of all regulations, the absence of adequate or on‐call staff for use at work pressures, the absence of standard equipment for identifying and preventing potential hazards, and the absence of updated equipment to increase prognosis at incident time (Davoodi et al, 2013).…”

“…One of the leading structural factors in dropping the quality of care is the lack of supplies and equipment. Evidence has revealed that the structural factors such as the upgrading of medical equipment affect the quality of the emergency structure (Zaboli et al, 2018; Zaboli, Shokri, Javadi, Teymourzadeh, & Ameryoun, 2016). The results of the studies showed that the major shortage of equipment in the emergency structure is effective (Kotsiou, Srivastava, Kotsios, Exadaktylos, & Gourgoulianis, 2018) and the shortage of basic equipment leads to delays in triage and adverse outcomes, misconceptions and inappropriate decisions (Aloyce, Leshabari, & Brysiewicz, 2014; Fry & Burr, 2001).…”

“…Another study noted that human resources and poor knowledge can be the reason for this delay (Cavallaro & Marchant, 2013; Knight, Self, & Kennedy, 2013). In addition, the structural factors can affect the quality of the emergency structure (Zaboli et al, 2016, 2018), including the determined job descriptions, human resources, physical space, skills and experience of staff, the recruitment of professional staff, training and updating of medical equipment (Zaboli et al, 2016, 2018). A study reported that the skill, competence and number of triage performers are some of the internal factors affecting decision‐making in the triage.…”

Analisis Fishbone dalam Meningkatkan Efektifitas Pelaksanaan Handover Di Rumah Sakit Pemerintah

“…Hal tersebut dapat menimbulkan bahaya bagi pasien bahkan berkontribusi dalam peningkatan kematian pasien (Saleem et al, 2015). Bahaya-bahaya yang muncul sebagian besar terjadi karena kurang efektifnya komunikasi antar petugas medis maupun tenaga kesehatan lainnya (Zaboli et al, 2018). Penelitian lain juga menunjukan bahwa pelaksanaan handover yang baik berdampak pada baiknya pengelolaan obat oleh perawat selama masa pandemic Covid-19.…”