Solutions
Sentinel Events
unexpected occurrence involving the death or serious
physical/psychological injury
These events are so serious that they trigger an investigation to
identify root causes and prevent reoccurrence
Sentinel Event Examples
1. Giving the wrong medication or dose which results in patient
death or paralysis
2. Performing surgery on the wrong limb
Characteristics of Sentinel Events
S&P
Severity = significant harm to patient (death, permanent
disability, or severe emotional distress)
Preventable = event not intentional and could have been
prevented w/ implementation of appropriate safety measures
Importance of Sentinel Event Investigations
Sentinel events provide valuable opportunities to learn from
mistakes and make improvement to patient safety
healthcare organizations can identify systemic weaknesses and
implement changes to prevent future harm
,Ethical Decision-Making
Developed by the ANA
essential to nursing practice because nurses often face complex
situations that require them to weigh different ethical principles
and make difficult choices
Autonomy
patient's rights to make their own decisions about their care or
their right to refuse care
Example of Autonomy
a patient refusing a blood transfusion because it would be
against their religion
Example of Violating Autonomy
Failing to provide education to a patient about a procedure
Beneficence
DO GOOD
acting in the best interests of the patient and promoting their
well-being
Non-maleficence
DO NOT HARM
avoiding harm to the patient and minimizing the potential for
negative consequences
Violation of non-maleficence
, There must be an intent to harm the patient
Justice
TREATING PATIENTS FAIRLY AND IMPARTIALLY
also ensuring equitable access to care, education and
opportunities as other patients do
Fidelity
KEEPING PROMISES
Example of Fidelity
If you tell a patient you will be back in 15 minutes, return in 15
minutes
Veracity
TELLING THE TRUTH
Example of Veracity
If a patient asks about their diagnosis then say the truth
regardless of family wishes
What do all ethical codes contain?
1. Respect for human dignity and uniqueness
2. Maintenance of nursing competence
3. Protection of confidential information
Ethical Decision - Making Process
1. Identify the ethical dilemma
2. Gather information - about patient's situation, wishes,
available options