Which of the following occurrences would be classified as a sentinel event?
a. A postpartum patient who elects to breastfeed only twice daily develops mastitis.
b. A newly diagnosed diabetic patient self-injects insulin in the abdominal area rather than the upper thigh as instructed by the patient educator.
c. A nurse assisting with the delivery of twins places the "Twin 1" name tag on the second-born twin, causing the first-born twin to undergo surgery that was scheduled for the other twin.
d. A nurse administers 3 units of regular insulin rather than 3 units of NPH insulin subcutaneously, resulting in a drop in the patient's serum glucose from 160 mg to 100 mg.
ANS: C
Correct: Any procedure performed on a wrong person or organ constitutes a sentinel event.
Incorrect:
a. The infection was not due to negligence of provider.
b. The patient chose the site and, although not the one indicated by the nurse, it was an appropriate site.
d. Although a medication error occurred, death or permanent loss of function did not occur.
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