Sentinel Event Analysis Learning Activity
University of Colorado Denver College of Nursing
Pre-Licensure ADN/Diploma, Pre-Licensure BSN
- Examine human factors and other basic safety design principles as well as commonly used unsafe practices.
- Demonstrate effective use of technology and standardized practices that support safety and quality.
- Value the contributions of standardization/reliability to safety.
- Appreciate the cognitive and physical limits of human performance.
- Value own role in preventing errors
- Describe processes used in understanding causes of error allocation of responsibility and accountability (such as root cause analysis and failure mode effects analysis).
- Discuss potential and actual impact of national patient safety resources, initiatives, and regulations.
- Use national patient safety resources for own professional development and to focus attention on safety in care settings.
- Value relationship between national safety campaigns and implementation in local practices and practice settings.
- Incomplete clinical information
- The language barrier
- Inconsistent procedure for communicating prenatal care
- Staff inexperience and poor documentation
- Nonstandard method of writing the drug order
- Insufficient drug information
- Lack of a unit dose system
- Insufficient information on infant injections
- Inconsistent independent double check system
- No staff education before dispensing nonforumlary drugs
- Insufficient drug information and inadequate drug references
- Unclear definition of nonphysician prescriptive authority
- Unclear manufacturer labeling
- Conflicting information on IV use of milky white substances