A nurse is removing a saturated dressing from an abdominal incision and must cut the tape to remove the dressing

Question

The nurse accidentally cuts the sutures holding the incision, and evisceration occurs. In quality improvement, this incident is best identified as a:
a. root cause.
b. sentinel event.
c. variation in performance.
d. causal factor.

Answer 1

ANS: B
Correct: A sentinel event is an unexpected occurrence that could result in serious physical or psychological injury to the patient, including the possibility of returning to surgery and a prolonged length of stay.
Incorrect:
a. A root cause analysis is the process by which basic or causal factors that underlie variation in performance, such as a sentinel event, are identified, but this process is not the event itself.
c. A variation results from the lack of perfect uniformity in the performance of any process, but when the variation is this serious, it is referred to as a sentinel event.
d. Causal factors are the underlying causes of the event, not the actual event.