Sentinel Event Case Study

Decent Essays
1. Define Sentinel Event and give an example.
An event that has adverse consequences to patients e.g. wrong site surgery or adverse reaction to a medication. A root cause analysis has to be done and reported to whoever is running the hospital.

2. When should medication reconciliation occur? Who is the primary person responsible for medication reconciliation at your site?
On arrival at the ER.
When there is a transition in the care on the floor
Into and out of surgery
Pharmacy technician in the ER
Nurses when going into and out of the unit.

3. How can the person doing medication reconciliation at your site verify the patient’s controlled substances?
Call physician or check with the pharmacy.
There is a controlled substance database that can be used to check.

4.
…show more content…
Review a patient profile and list all medications with MOA and main side effects.
Vancomycin
• Inhibits the synthesis of bacteria cell walls and interferes with their RNA synthesis.
• The most common side effects are hyperkalemia, diarrhea, nausea, vomiting and abdominal pain.
Aspirin
• COX 1 and COX 2 inhibitor.
• The main side effects are: Gastrointestinal upset, bronchospasm, gastric ulcer, tinnitus and hemorrhage

Lisinopril
• Lisinopril is an ACE inhibitor.
• Its main side effects include: Hypotension, chest pain, dizziness, syncope, headache and cough
Warfarin
• It inhibits the synthesis of vitamin k dependent clotting factors by inhibiting vitamin k-2,3 epoxide reductase.
• The main side effects include: alopecia, bleeding and hypersensitivity

5. Give at least 5 examples of “look alike/sound alike” medications.
Hydralazine and hydroxyzine
Dopamine and dubutamine
Bupropion and buspirone
Prednisone and prednisolone
Epinephrine and ephedrine

6. Give examples of methods to prevent dispensing errors.
Bar coding system
Auxiliary stickers to remind the nurse to check the medication
Put them in different places on the shelf

7. What is HCAHPS?
Hospital Consumer Assessment of Healthcare Providers and

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