ICP scenarios: Is it a sentinel event?

Key questions will lead to answer

Denise Murphy, RN, MPH, CIC, chief of patient safety at Barnes Jewish Hospital at Washington University Medical Center in St. Louis, and colleagues developed the following scenarios to assist infection control professionals in identifying sentinel events related to infections.1 The complete document is available on the Association for Professionals in Infection Control and Epidemiology web site at www.apic.org.

Scenario # 1

A 73-year-old male was admitted with aortic stenosis. The patient also had diabetes mellitus. He underwent an aortic valve replacement. He had an uneventful recovery and was ready for discharge nine days post-op.

On the day of discharge, the staff RN was removing the saline lock from the right forearm. The nurse noticed a small, reddened area around the site. The nurse reported the findings to the physician, who ordered wet soaks, but did not delay the discharge. The patient’s temperature was 99.4º F. This was not reported to the physician. Twenty-four hours after discharge, the patient was readmitted with a temperature of 103ºF and was acutely ill. Cultures from the saline lock site, spinal fluid, blood, urine, and sputum were all positive for Staph aureus. The patient expired.

Would this be considered a sentinel event?

While the risk of any operative procedure certainly includes infection, this patient’s infection and death were most likely not related to his surgical procedure. He had a very normal postoperative course. There appeared to be an infection starting at his IV site that was left untreated. While we cannot say with 100% certainty that the true source of infection was the IV site, it did appear this was the proximate cause of his ultimate demise.

A root-cause analysis (RCA) in this unexpected death would analyze several systems issues:

  • What is the policy for changing saline locks?
  • What are the assessment expectations if the saline lock is not changed?
  • Does this nursing unit have a policy that all patients on their unit will have a saline lock, regardless of the patient condition?
  • Were the nurses doing the assessment competent in assessment and maintenance of IV saline locks?
  • Was the appropriate information communicated to the physician?
  • Were the staffing levels appropriate for the needs of the patients on this unit?
  • Did the nurses feel rushed to discharge a patient?
  • Were there other factors that could have potentially diverted the nurse from conveying all necessary information to the physician prior to discharge?
  • Should the physician have delayed discharge?
  • Were there external factors influencing the surgeon’s decision to discharge (monitoring of length of stay by the MD group for example)?

Typically, several systems issues will be identified that will result in a plan of action. In this case, it may be policy and procedure changes, staff competency assessment, and peer review.

Scenario #2

A 9-year-old child was admitted to the pediatric unit with acute lymphocytic leukemia. This was a new diagnosis for this patient.

Following six weeks of chemotherapy in the hospital, her immune system became extremely compromised. She was maintained in an isolation room for the last three weeks of therapy as her white count had dropped to very low levels.

During week six in the hospital, the child spiked a fever to 104°F and became tachycardic. She complained of a new onset of pain in her head. This was reported to the oncologist immediately and cultures were obtained from blood, nasopharynx, and spinal fluid.

The spinal fluid and NP cultures grew Aspergillus fumigatus. Despite aggressive treatment, the child was taken to the operating room for removal of her left eye and cheekbone to prevent further damage from the Aspergillus. She was ultimately discharged home.

Would this be considered a sentinel event?

Some ICPs would argue that infections of this nature are a rare but well-known complication of this diagnosis and treatment regimen. This could be considered permanent loss of function. Many safeguards were probably put in place to prevent this tragic outcome. This event would warrant intense analysis at a minimum. An intense analysis — or perhaps, RCA — could analyze several systems issues:

  • What engineering controls are in place to prevent acquisition of Aspergillus?
  • Were the engineers adequately oriented and trained in the role of environmental pathogens for this patient population?
  • What education and training did the nurses receive for this high-risk patient population? How are new employees oriented?
  • What is the staffing ratio for these children?
  • Do the assignments require nurses or other members of the health care team to care for children with infection as well as these immune-suppressed children?
  • What equipment was involved in the care of this patient?
  • Were there any system breakdowns in cleaning processes?
  • Are medical staff working with these patients educated on appropriate barrier precautions and hand hygiene?
  • Was there any construction going on in or around the facility?
  • Were the parents taught about hand hygiene?
  • Because the ICP comes armed with the knowledge of microorganisms and how they are introduced or spread, the ICPs knowledge will be invaluable in reviewing the systems issues associated with this type of event.


1. Frain J, Murphy D, Dash G, et al. Integrating Sentinel Event Analysis into Your Infection Control Practice. Washington, DC: Association for Professionals in Infection Control and Epidemiology; January 2004. Web: www.apic.org.