12 hour shifts, extended work periods, voluntary and mandatory overtime, and excessive workloads are all factors that dangerously contribute to nurse fatigue, which has led to a number of medication errors and sentinel events (Rogers, Hwang, Scott, Aiken, & Dinges, 2004). In the 2004 study by Rogers, Hwang, Scott, Aiken, & Dinges, it was found that the longer the shift, the risks for errors increases. Also, when working longer than 17 hours without sleep, nurse fatigue has been shown to demonstrate the equivalence of being under the influence with a blood alcohol concentration of 0.05% (Garrett, 2008). The effects of fatigue on nurses includes problems such as: compromised problem-solving skills, decreased attention span, delayed reaction time, memory lapses, impaired communication, and inability to focus, which are all important for nurses to be aware of in order to provide quality and safe patient care (Warren & Tart, 2008). The evidences and dangers of nurse fatigue linked to adverse events from the long work hours and cumulative days of extended work hours has been greatly recognized by The Joint Commission (TJC) issuing a sentinel event alert on December 14, 2011, regarding health care worker fatigue and patient safety (The Joint Commission, 2011). So, I will be discussing the following in the paper that includes: explanation of reviewable sentinel events, a specific sentinel event related to nurse fatigue, and its root cause analysis.

Explanation of Reviewable Sentinel Events

As defined by TJC, a sentinel event is an unexpected occurrence involving either death, serious physical or psychological harm, or the risk thereof that prompts the need for immediate investigation and response (Sentinel Events Policy and Procedures, 2012). But, for a sentinel event to be considered reviewable, it must meet any of the following criteria:

the event resulting in an unanticipated death, coma, permanent loss of function, unrelated to the natural course of the patient’s illness or underlying condition, or

the event is one of the following, but not limited to:

suicide within 72 hours of being discharged from a 24 hour care setting

rape, sexual abuse/assault

elopement

abduction (Sentinel Events Policy and Procedures, 2012).

A Specific Sentinel Event Related to Nurse Fatigue

On July 5, 2006, Jasmine Gant, a pregnant 16 year old high school student, arrived with her mother at St. Mary’s Hospital in Madison, Wisconsin at 9:30 A.M. for her scheduled induction (Smetzer, Baker, Byrne, & Cohen, 2010). The Labor and Delivery (L&D) nurse assigned to care for Ms. Gant that day was Julie Thao, 41 years old. Mrs. Thao had been working at St. Mary’s Hospital since 1993, and worked in the L&D department for 15 years. The day before July 5, 2006, Mrs. Thao had voluntarily worked a double shift for a total of 16 hours or more to cover for the unit’s short staff. Mrs. Thao was extremely fatigued by the end of her shift that ended at midnight. She spent the night at the hospital to avoid her hour long commute home and because she was due for her next shift at 7 A.M. So on the morning of July, 5, 2006, the very fatigued nurse Mrs. Thao started her shift caring for one expectant mother. When Ms. Gant presented at the L&D unit later that morning, Mrs. Thao spent time with her and her mother completing the admission process that is done with every admitting patient. However, Mrs. Thao did not apply a bar-coded identification band to Ms. Gant’s arm at this time (Smetzer, Baker, Byrne, & Cohen, 2010). When discussing pain management, Ms. Gant expressed the possibility of wanting to use epidural, which Mrs. Thao would relay the message to the obstetrician.

At 11:30 A.M., Ms. Gant’s physician arrived to her room to rupture her amniotic membrane. The physician told Mrs. Thao that he planned to check back before determining with the patient the need for epidural. In the meantime, he had ordered Pitocin, Lactated Ringer’s (LR) solution, and intravenous (IV) penicillin to treat a strep infection that Ms. Gant had. While Mrs. Thao was in the room, the patient communicated to her that she was anxious about receiving epidural. So, Mrs. Thao thought it would be a good idea to retrieve epidural solution, Bupivacaine, to show the patient and in anticipation since the Anesthesiologist would get upset for not having it readily available.

Now, St. Mary’s Hospital had just started transitioning and training the employees in using the newly installed bar coded medication administration system. Apparently, the hospital was currently having problems with it, so the nurses were instructed to give the medications when needed and document them manually. Well, Mrs. Thao bypassed the system to remove the Bupivacaine, which she also did not have authorization or permission to do so for that medication. Then, she gathered the LR solution and Pitocin before walking back into the patient’s room. On the way, another nurse handed her the IV penicillin. When Mrs. Thao entered the patient’s room, she sat the supplies on the counter and began to prepare and initiate the IV infusion. Carelessly, Mrs. Thao made the fatal mistake and grabbed the epidural solution instead of the penicillin, both looking very similar in appearance, administering it intravenously into Ms. Gant’s arm. Unknowingly of the mistake she had just done that would soon cost her nursing career and her patient’s life, Mrs. Thao went on to rewinding the tape on the birthing process to play for the patient, her mother, and the baby’s father who had just showed up creating lots of tension. Within minutes, the patient’s mother terrifyingly screamed for mercy. At this point, her daughter was in respiratory distress, seizing, and into a cardiac arrest. The frantic nurse immediately called the rapid response team and code blue. Every effort was made to resuscitate Ms. Gant, but she remained asystolic. Ms. Gant was immediately taken to the operating room to have an emergency cesarean section where the physicians delivered an 8 pound healthy baby boy. The health care team continued resuscitating Ms. Gant, but was pronounced dead by 1:43 P.M. After ruling out several possible causes of her death, it was discovered minutes later that the infusing bag was the epidural solution, instead of the penicillin (Smetzer, Baker, Byrne, & Cohen, 2010). Her colleagues reported that Mrs. Thao looked extremely fatigued, which possibly increased her likelihood of making the fatal medication error along with the omission to verify the five rights of medication administration.

The Root Cause Analysis

A root cause analysis (RCA) is a technique used to help identify the possibilities of causes that led to the end result. When a sentinel event occurs, the hospital is accountable to do a root cause analysis. The point of RCA is not to point out who is to blame. Thus, by conducting a RCA, it allows for a plan of action to prevent the same or similar incidents from occurring. The first part of the RCA is defining the problem or effect. Part two is determining why it happened with the cause and effect technique. Part three is generating solutions and implementing a plan of action to reduce the likelihood of the event from happening again.

In the sentinel event above, the problem was a medication error by registered nurse (RN) Julie Thao that had resulted in the maternal death of 16 year old expectant mother, Jasmine Gant. The four cause categories formulated for this specific case are: people, work environment, equipment, and policies and procedures.

The nurse Mrs. Thao’s fatigued had a tremendous effect on the actions leading to the medication error. She had voluntarily worked a back to back shift of 16 hours or more the night before starting work again the next morning. She expressed the desire to go home halfway through her second shift, too. While taking care of Ms. Gant, the nurse was distracted while preparing the medications. Mrs. Thao reported that there was tension in her patient’s room when the baby’s father arrived, so she had intended to administer the IV penicillin and put on the educational video of the birthing process.

The work environment of the L&D unit that Mrs. Thao worked on was not well organized. The nurses did not directly communicate with the Anesthesiologist making it difficult to have the epidural ready upon their arrival. The unit was also short staffed with several nurses on temporary leave (Smetizer, Baker, Byrne & Cohen, 2010). If Mrs. Thao had not worked second shift, they would have been inadequately staffed. The staff and managers did not strictly enforce and comply with the policies such as the identification bands and bar code medication administration system.

So, the problems associated with the policies and procedures included the delay of the patient’s identification bar code band application, omission of verifying the five rights of medication administration, and retrieving the epidural before it was ordered. The issue with the delay of the patient’s identification band was that it took longer for the bands to be made with the new system. The staff and management were lenient and made it a norm to put it on the patient whenever it was a convenient time. However, Mrs. Thao confessed that she did not comply with the five rights of medication administration. Also, she retrieved the epidural before it was ordered to decrease her patient’s fear and in anticipation of early epidural. Retrieving the epidural in anticipation upon the Anesthesia’s arrival was a common practice on the L&D floor because of the dissatisfaction expressed by some Anesthesiologist of it not being readily available.

For equipment, there was the problem of the newly installed bar code medication administration system and the design of the bag of epidural solution and IV penicillin. The new system’s constant problems created low rates on compliance on scanning IV bags, and nurses bypassing the system, which included safety features to prevent such errors from happening. The L&D unit staff had inadequate training on troubleshooting the system, especially Mrs. Thao. Instead, management allowed them to hang the medications and document them manually. With the mistake of grabbing the wrong bag, Mrs. Thao had brought all the supplies including the two bags from the anteroom and sat them onto the counter near the patient’s bedside so that she can converse with the patient directly. The bag containing the epidural solution and the bag of the penicillin looked similar in size, but the epidural was slightly bigger. They were both clear solutions. The two bags both had orange label stickers, but the epidural bag had an additional bright pink warning label. There is also a design flaw in the interconnectivity making the IV tubing compatible with accessing the epidural bag port like it does with the IV solutions (Smetizer, Baker, Byrne & Cohen, 2010).