The Joint Commission publishes a Sentinel Event Alert every month. Which of the following is the best example of a sentinel event?
a. Tylenol #3 is given to a patient when plain Tylenol was ordered.
b. Code pink is called after a newborn is discovered missing from the nursery.
c. After receiving the correct medication, the patient complains of itching all over, and a rash is noted on the patient's trunk.
d. During a blood transfusion, the patient's temperature increases to 100.4° F, and the patient complains of generalized pruritus.
B
A sentinel event is an unexpected occurrence involving death or loss of limb or function. Exam-ples of sentinel events include serious medication errors, significant drug reactions, surgery per-formed on the wrong body site, blood transfusion reactions, and infant abductions.
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