Running head: SENTINEL EVENT 1

Sentinel Event

Chelsea Ruthrauff

California State University, Stanislaus

December 17, 2019

Sentinel Event

In the medical field, an error has the potential to result in dire consequences. A single

mistake may drastically change the lives of all parties involved. Healthcare workers face life or

death decisions on a regular basis. A sentinel event is not always as simple as one person

making one mistake, but may encompass a variety of components (The Joint Commission

[TJC], 2015). Among many things, these components include the people involved,

communication techniques, technology, and work environment. While sentinel events may be

caused by multiple factors, it has been proven that disruptive behaviors in the workplace increase

the risk of adverse patient outcomes (TJC, 2008). Disruptive behaviors include both passive and

aggressive behaviors in which an individual is made to feel intimidated or bullied. A key

characteristic of disruptive behavior, is the disconnection caused between members of the

healthcare team. This disturbance impairs teamwork capabilities and places the patient at risk

(TJC, 2008). ​This paper will define the concept of a sentinel event, discuss an occasion

where disruptive behavior resulted in a sentinel event, perform a modified root cause

analysis of the event, and suggest evidence based solutions to prevent future events.

Sentinel Event

In 2019, TJC released a specific policy and procedure related to sentinel events. A

sentinel event is described as any medical error which resulted in death, permanent injury, or

temporary harm requiring life-saving interventions (TJC, 2019). When these events occur, the

hospital must perform an analysis of the circumstances that occurred prior to the sentinel event.

Rather than invoking blame, the analysis of the sentinel event helps to identify and modify issues

within the hospital systems and processes in order to lower patient risk. TJC also recommends

that hospitals self-report sentinel events in order to improve the culture of safety and to provide

assistance with the analysis of the event (TJC, 2019).

True Story

In July 2014, Monica was hired on as a nurse in the Neonatal Intensive Care Unit (NICU)

in a hospital in Oakland, California. She was new to the area and had yet to make any friends.

On Monica’s first day, she was oriented by Carla, another nurse in the NICU, and the two

became fast friends. By August, the two nurses had worked many shifts together and even spent

time together outside of work. The pair decided to plan a road trip to San Diego, California for a

vacation.

The trip to San Diego went very smoothly. Monica and Carla spent time laughing,

relaxing, and getting to know each other. However, on the way back, malice was in the air.

Carla offered to drive, but made it clear that she was not in the mood to talk. Monica was

content to read in silence while Carla drove them back to Oakland. Suddenly, Carla snapped,

“Why don’t you make yourself useful and help me with directions!”. “I ​thought​ you knew where

you were going” Monica snidely remarked, as she pulled out the map. “Hurry up, you’re so

slow!” whined Carla. The car continued to barrel down the stretch of highway in the far left

lane. “I think we need to take this exit”, Monica hesitantly stated as the car raced past the exit

and merged onto a new freeway. “Great!” shouted Carla sarcastically, “Now we’re going the

wrong direction. Thanks a lot”. This comment spiraled into a brutal argument. The remainder of

the drive was spent in deafening silence.

The following day, Monica arrived at work and overheard Carla laughing in the

breakroom. She arrived just in time to hear Carla tell their coworkers that Monica was

“illiterate”, “stupid”, and “unfit to care for patients”. Monica spent the rest of her shift holding

back tears. Through August, the two nurses refused to speak or work with each other. The nurse

manager accommodated these requests by rearranging the schedule to prevent the nurses from

interacting.
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On September 1, 2014, Carla and Monica’s primary patients were placed in adjoining

nurseries. The nurses were forced to either work in the same proximity or give up their primary

patients to other nurses. Both Monica and Carla chose to care for their primary patients. After

report, Carla marched into her nursery and angrily slammed the door shut between the two

nurseries. Throughout the day, Monica utilized other nurses for co-signatures on medications

and assistance with her patient. She preferred taking the extra time to seek out another nurse

rather than risk evoking Carla’s rage. Towards the end of her shift, Monica left her patient alone

in order to obtain a co-signature for breast milk. The unit was understaffed that day, so she

wandered the halls looking for someone to help her. During this time, her patient self-extubated

and coded. The piercing alarms went off alerting the staff that something was wrong. Carla was

unable to hear the alarms through the thick wooden door. At the time, multiple alarms were

going off in various patient rooms. The nurses in the station assumed that the situation was

under control and failed to respond. Minutes went by. When Monica returned to the room, she

found that the patient could no longer be revived.

Root Cause Analysis

A root cause analysis (RCA) is a tool used to determine the root cause of a sentinel event

and propose solutions to prevent similar events from occurring in the future (Quality Assurance

and Performance Improvement, 2019). This analysis is typically composed of a series of seven

steps. The first step involves identifying an event in which an RCA would be beneficial. In step

two, an analysis team is assembled and a team leader is chosen. Next, the story of the event must

be told objectively in order to properly identify root causes and contributing factors.

Contributing factors are identified in the fourth step. These include potential factors or events

that may have played an additional role in the occurrence of the sentinel event. Root causes are

then identified and analyzed. Root causes are not direct causes of the event, but rather
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underlying systemic factors that increased the likelihood that the sentinel event would occur.

Evidence based solutions are then proposed and implemented in order to eradicate the identified

root causes. Finally, these solutions are evaluated to determine if an effective change has been

made. The goal of an RCA is to identify root causes and remove them from the system in order

to increase safety, improve patient outcomes, and prevent future sentinel events (Quality

Assurance and Performance Improvement, 2019).

People

In the assessment of the true story of a sentinel event, root causes are related to nurse

fatigue and inadequate staffing. One primary factor in the sentinel event, was Monica’s inability

to find a nurse available to cosign for the breast milk. This led to increased time that the patient

had no supervision. This may indicate the lack of appropriate staffing during this shift in the

NICU. It has been found that inappropriate staffing produces higher stress to the work

environment (American Nurses Association, 2019). Adequate staffing improves both the safety

and the quality of patient care and produced an improvement in patient outcomes and satisfaction

(American Nurses Association, 2019). An additional factor that played a role in the sentinel

event was the fact that Monica was nearing the end of her 12 hour shift. 12 hour shifts have a

28% higher risk of error caused by fatigue as compared to 8 hour shifts (Caruso, 2014). Adverse

events in the hospital setting have a direct correlation to health care worker fatigue (TJC, 2011).

Communication

Two major root causes related to communication involved a lack of communication and

unresolved conflict between two nurses. When Monica left the room to obtain a co-signature for

breast milk, she failed to inform anyone that she would be leaving her patient unattended. Had

Monica communicated with another nurse, that nurse may have been able to either sign for the

breast milk in the room or attended to the patient while Monica was out of the room. Failure to
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communicate effectively is a leading cause of harm to patients (Shitu, Hassan, Aung,

Kamaruzaman, & Musa, 2018). Another primary factor is that the unresolved conflict between

Monica and Carla prevented Monica from communicating with Carla. Had Monica utilized

Carla to sign for the breast milk or monitor the patient while she was gone, the patient would not

have been left unattended. Strong interpersonal relationships among nurses have resulted in

higher quality patient care (Shah, 2017). The sentinel event story is an excellent example of how

poor interpersonal relationships my result in poor patient outcomes.

Technology

An additional root cause of the sentinel event relates to complications regarding

technology. When the alarm indicating that the patient had self-extubated went off, the nurses at

the nurses' station failed to respond. This appears to be an indication of alarm fatigue. Alarm

fatigue typically occurs due to sensory overload (Advancing Safety in Medical Technology,

2011). The goal of alarm systems is to produce a unique sound that alerts medical professionals

to the current highest priority. In the hospital setting, the high frequency of alarms has been

found to cause nurses to ignore the alarms; simply because the nurses have become numb to

hearing the same, frequent sounds. The alarms no longer function as a new, alerting sound, but

one that blends into the background (Advancing Safety in Medical Technology, 2011). In the

sentinel event story, if the nurses had responded to the alarms immediately, advanced life support

could have been initiated. It is also vital to discuss the assessment and placement of the

endotracheal tube. Self-extubation is one of the most common adverse events that occurs within

a NICU setting (Lucas da Silva, Reis, Aguiar, & Fonseca, 2013). One way that self-extubation

can be prevented is through proper assessment and anchoring of the endotracheal tube.

Implementing these precautions reduces the rate of infant self-extubation in the NICU (Lucas da

Silva, et al., 2013).

Work Environment

A potential root cause of the sentinel event is the work environment in which this event

occurred. The environment was both hostile and unprofessional. Carla’s disruptive behavior

caused Monica to feel too intimidated to ask Carla for help. During the time that Monica spent

seeking out another nurse, the baby self-extubated, resulting in death. The three primary

categories of workplace violence exhibited by Carla include threat to professional standing,

isolation, and threat to professional status. Threat to personal standing may include actions such

as verbal insults or name calling (TJC, 2016). Isolation typically refers to keeping important

information from another person (TJC, 2016). In the sentinel event story, Carla exhibited

isolation by shutting the door and preventing Monica from using her as a resource. Threat to

professional status involves humiliation in front of peers and coworkers (TJC, 2016). Bullying in

the workplace creates a negative work environment that has the potential to compromise the

safety of patients (TJC, 2016). Additionally, the nurse manager was aware of the issue and

accommodated shift requests rather than address the issue. There were also no zero-tolerance

policies in place to address disruptive behavior. Lack of managerial reporting of bullying is

common in the hospital setting (Taylor, 2016). This is often due to unclear policies and

undefined concepts of violence in the workplace (Taylor, 2016). An integral aspect of the nurse

manager role is conflict management between nurses (Johansen, 2012). Had the nurse manager

addressed the issue of incivility, Monica and Carla would have been forced to manage their

interpersonal conflicts prior to care of patients.

Action Plan

After the root causes of a sentinel event are identified, the next step of the RCA is to

create an action plan in which to implement change (Quality Assurance and Performance

Improvement, 2019). Two vital aspects of action planning involve designing specific
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interventions and determining how the effectiveness of these interventions will be evaluated

(Agency for Healthcare Research and Quality, 2018). Each intervention developed must target a

specific root cause. Once the intervention has been implemented, the effectiveness should be

evaluated in order to determine if the changes have been beneficial. If the intervention is not

effective in addressing the root cause, a new intervention should be initiated (Agency for

Healthcare Research and Quality, 2018).

The action plan for this sentinel event will utilize Kurt Lewin’s Change Management

Model. Lewin’s Change Model is a tool used to discuss change theory (MindTools, 2019). This

model consists of three parts: Unfreeze, change, and refreeze. The goal of this tool is to assist in

the anticipation of each step of the change process (MindTools, 2019).

Unfreezing

During the unfreezing stage of Lewin’s Change Model, the goal is to display evidence to

show that change is necessary (MindTools, 2019). Similar to a block of ice, unfreezing allows

for the potential for it to be reshaped. In the same way, an institution must acknowledge and

need for change and be receptive to change. During the unfreezing stage, core beliefs, values,

and attitudes are often questioned because change must come from the core of the institution.

This disrupts the system and allows it to be rebuilt (MindTools, 2019). In the case of this

sentinel event, the unfreezing stage is facilitated by the death of the newborn. The patient’s

death has functioned as a catalyst in the reaction of change by encouraging the nurses to

understand the need for change.

Changing

The changing stage of Lewin’s Change Model, is the stage in which the people involved

begin to adapt to the implemented changes (MindTools, 2019). New ideas are more accepted as

opposed to the questioning involved in the unfreezing stage. People begin to change behaviors
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in support of the change. Time is a valuable component of the change phase. Significant

transitions require an ample amount of time to gradually take root within the system before the

refreezing stage of the change model can occur. An additional component of the change phase is

communication. The success of the change is improved if people understand how the change

will benefit them (MindTools, 2019).

Targeted Change: People

The root causes associated with people include poor judgement related to inadequate

staffing and nurse fatigue. In order to address inadequate staffing, the hospital will assess

amount of staffing per floor (Miller, 2019). Despite California laws that help to regulate

nurse-to-patient ratios, inadequate floor staffing causes nurses to work more frequently, causing

burnout, poor retention rates, and a decrease in patient satisfaction. Safe staffing has been proven

to increase positive patient outcomes and promote nurse retention rates (Miller, 2019). In order

to manage nurse fatigue, hospital policies will be updated and nurses will be educated on

adequate staffing and the implications for patient safety.

Nursing errors are more likely to occur in the last four hours of twelve hour shifts (Wong,

2017). However, the majority of nurses do not support reducing the length of shift time to eight

hours. In order to address this issue with an alternative option, those in charge of scheduling will

separate shifts throughout the week rather than scheduling multiple days in a row. This reduces

the chance of nurse fatigue (Wong, 2017). Additionally, the floor will implement a fatigue

management plan (TJC, 2011). The fatigue management plan will educate nurses on how to

obtain the most amount of sleep at home, teach about strategic caffeine use, encourage teamwork

and accountability on night shifts, and promote brief physical activity as a group throughout the

shift. These methods are strongly encouraged by TJC in order to reduce nurse fatigue (TJC,

2011).
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Targeted Change: Communication

In the hospital setting, conflict and communication often go hand-in-hand (Moreland &

Apker, 2016). Poor communication can cause conflict, and conflict may result in impaired

communication. Effective communication during conflict will lead to teamwork and

collaborative efforts to solve problems (Moreland & Apker, 2016). Monica and Carla’s

interactions at work were a clear example of poor communication and poor conflict management.

This scenario provided evidence that both floor nurses and charge nurses were unprepared to

handle conflict. This will be corrected through the use of conflict resolution training (Lachman,

2014). The unit will enforce yearly conflict resolution training with the use of the Interest-Based

Relational Approach (IBR) (MindTools, 2019). This approach encourages relationships by

respecting and listening to others. It values the person over the problem and seeks out a

team-based approach (MindTools, 2019). Training in communication and conflict management

is a positive step in preventing future sentinel events.

Targeted Change: Technology

Alarm fatigue is caused by a variety of factors (Ensslin, 2014). These include narrow

alarm parameters, lack of alarm customization for individual patients, malfunctioning alarms,

and poor electrocardiogram (ECG) connection. Each of these results in an increase of

unnecessary alarm sounds resulting in alarm fatigue (Ensslin, 2014). In order to address these

factors, an interprofessional team specifically dedicated to alarm management will be

implemented (American Association of Critical Care Nurses, 2018). This team will assess

specific policies and procedures related to alarm management. One new policy will explain that

nurses will check alarm settings to ensure accuracy at the beginning of each shift. Alarm

parameters will also be customized per individual patient. These interventions will decrease the
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amount of false alarm sounds, thus reducing the risk of alarm fatigue in nurses (American

Association of Critical Care Nurses, 2018).

In order to decrease unplanned extubation events, the hospital will utilize unplanned

extubation prevention guidelines, define and standardize the securing of endotracheal tubes,

educate staff on frequent checks, and require two healthcare providers to reposition a patient

(Crezee, DiGeronimo, Rigby, Carter, & Patel, 2017). The use of these methods reduced the rate

of unplanned extubations by 64%. Unplanned extubation prevention guidelines include the

standard for proper tube placement as well as adequate head positioning. The endotracheal tube

tube has a greater chance of coming out if the head is not maintained at a neutral position.

Endotracheal tube securement will be defined, based on evidence-based practice. The nurse will

then have a standard to determine if tube placement has been compromised. In addition to this

standard, education on frequent tube placement checks will be implemented in order to

thoroughly assess the risk for unplanned extubation. Finally, the usage of two healthcare

providers to reposition a patient has proven to prevent the dislodging of endotracheal tubes,

which may place the patient at risk for unplanned extubation (Crezee, et al., 2017). This

information will be implemented through mandatory training for all nurses on the unit in order to

decrease the risk of a future sentinel event.

Targeted Change: Work Environment

In order to discourage lateral (horizontal) violence in the workplace, the problem must be

addressed at multiple angles (Lachman, 2014). Workplace violence is a form of disruptive

behavior which increases the risk of a sentinel event (TJC, 2008). Typically, workplace violence

is a multidisciplinary issue requiring a variety of interventions (Lachman, 2014). Nurses working

in a violent environment typically are not aware of the proper code of conduct and, as such, do

not recognize instances of poor conduct as lateral violence (Taylor, 2016). This leads to a lack of
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reporting and lack of intervention by management (Taylor, 2016). In order to address these

issues, standards of conduct will be clarified on units (Lachman, 2014). This will be done during

huddles in the morning for current staff and will be included in orientation for new employees.

A new zero-tolerance policy for disruptive behavior will be put into effect. If a nurse is reported

for lateral violence, the charge nurse will be responsible for having a discussion with the reported

nurse in order to determine the cause of the situation. The nurse will also be formally disciplined

and will be required to undergo violence prevention training. An additional intervention is skill

development through conflict resolution training (Lachman, 2014). Conflict resolution training

will teach nurses how to adequately identify and cope with instances of lateral violence

(Lachman, 2014). All nurses on the unit will undergo conflict resolution training in order to

prevent a future sentinel event. Contributing factors for lateral violence include territorial

behaviors of nurses, seniority, difference in education, and insecurities (Granstra, 2015). This

contributes to a hostile culture within the workplace. Recommended interventions involve

workplace culture awareness seminars and encouraging a positive climate in the unit (Granstra,

2015). Cultural awareness seminars will be held once a year to educate on a positive workplace

climate. The charge nurses will also implement a kindness incentive program to encourage

nurses to acknowledge positive behavior. Nurses will nominate co-workers for acts of kindness

and one nurse will be chosen and rewarded once a month. This will promote the recognition of

positive workplace behavior.

Refreezing

The refreezing stage of Lewin’s Change Model is a significant stage in which the new

changes are embraced by the institution. Typically, this means that the changes have been

internalized into core values that are now supported and expressed by the organization as a

whole. Stability ensues within the system and those involved with the change are able to receive
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closure. This step is vital in producing constancy and supporting change in the future

(MindTools, 2019).

Healthcare workers face difficult decisions on a regular basis. Each action made by the

nurse has the potential to affect the care of the patient. Nurses have a responsibility to promote

patient safety (Quality and Safety Education for Nurses, 2019). Sentinel events typically occur

as a result of multiple root causes that affect the system as a whole (TJC, 2015). One of the

primary root causes of a sentinel event is disruptive behavior in the workplace (TJC, 2008).

Disruptive behavior includes acts of bullying, incivility, and violence between nurses. These

actions have the ability to disturb the workplace environment and risk patient safety (TJC, 2008).

Any action or behavior that places a patient’s life at risk is unacceptable. This paper defined the

concept of a sentinel event, introduced a case study in which a sentinel event occurred, and

performed a root cause analysis of the event. The root cause analysis assessed factors associated

with people, communication, technology, and work environment and then presented evidence

based options for change.

Fishbone
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References

Advancing Safety in Medical Technology. (2011). ​Clinical alarms: 2011 summit​. Retrieved from

http://s3.amazonaws.com/rdcms-aami/files/production/public/FileDownloads/Summits/2

011_Alarms_Summit_publication.pdf

Agency for Healthcare Research and Quality. (2018). ​The ten steps of action planning​. Retrieved

from https://www.ahrq.gov/teamstepps/instructor/essentials/implguide1.html

American Association of Critical Care Nurses. (2018). ​Practice alert outlines alarm

management strategies.​ Retrieved from

https://www.aacn.org/newsroom/practice-alert-outlines-alarm-management-strategies

American Nurses Association. (2019). ​Nurse staffing​. Retrieved from

https://www.nursingworld.org/practice-policy/nurse-staffing/

Caruso, C.C. (2014). Negative impacts of shiftwork and long work hours. ​PubMed Central 39​(1)

16-25. doi:10.1002/rnj.107

Crezee, K.L., DiGeronimo, R.J., Rigby, M.J., Carter, R.C., & Patel, S. (2017). Reducing

unplanned extubations in the NICU following implementation of a standardized

approach. ​Respiratory Care 62(​ 8) 1030-1035. doi:

10.4187/respcare.0459810.4187/respcare.04598

Ennslin, P. (2014). Do you hear what I hear? Combating alarm fatigue. ​American Nurse Today.​

Advanced online publication. Retrieved from

https://www.americannursetoday.com/hear-hear-combating-alarm-fatigue/

Granstra, K. (2015). Nurse against nurse: Horizontal bullying in the nursing profession. ​Journal

of Healthcare Management 60​(4) 249-257. Retrieved from

https://journals.lww.com/jhmonline/Fulltext/2015/07000/Nurse_Against_Nurse__Horizo

ntal_Bullying_in_the.6.aspx?casa_token=kxbqMKscGIoAAAAA:p9CHZQt33DY38UtZ
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6L7MiOl3ExGFTLT1BCypCdXZdlCWdUVDLMvPJMI9qClac_XHMgzZKdlpvCOKQI

DWCX0JTMzs

Lachman, V.D. (2014). Ethical issues in the disruptive behaviors of incivility, bullying, and

horizontal/lateral violence. ​MedSurg Nursing 23​(1) 56-60. Retrieved on from

https://www.utc.edu/nursing/pdfs/classes/lachman-bullying.pdf

Lucas da Silva, P.S., Reis, M.E., Aguiar, V.E., & Fonseca, M.C.M. (2013). Unplanned

extubation in the neonatal ICU: A systematic review, critical appraisal, and

evidence-based recommendations. ​Respiratory Care 58​(7) 1237-1245. doi:

https://doi.org/10.4187/respcare.02164

Johansen, M. (2012). Keeping the peace: Conflict management strategies for nurse managers.

Nursing Management 43(​ 2) 50-54. doi: 10.1097/01.NUMA.0000410920.90831.96

Miller, E. (2019). ​Safe staffing: Critical for patients and nurses​. Retrieved from

https://dpeaflcio.org/wp-content/uploads/Safe-Staffing-2019.pdf

MindTools. (2019). ​Conflict resolution.​ Retrieved from

https://www.mindtools.com/pages/article/newLDR_81.htm

MindTools. (2019). ​Lewin’s change management model​. Retrieved from

https://www.mindtools.com/pages/article/newPPM_94.htm

Moreland, J.J. & Apker, J. (2016). Conflict and stress in hospital nursing: Improving

communicative responses to enduring professional challenges. ​Taylor and Francis Online

31​(7), 815-823. doi: 10.1080/10410236.2015.1007548

Quality and Safety Education for Nurses. (2019). QSEN competencies. Retrieved from

https://qsen.org/competencies/pre-licensure-ksas/
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Quality Assurance and Performance Improvement. (2019). ​Guidance for performing root cause

analysis (RCA) with performance improvement projects (PIPs).​ Retrieved from

https://www.snfqapi.com/resources/root-cause-analysis

Shah, M. (2017). Impact of interpersonal conflict in healthcare setting on patient care; the role of

nursing leadership style on resolving the conflict. ​Nurse Care Open Access 2(​ 2) 44-46

doi: 1015406/ncoaj.2017.02.00031

Shitu, Z., Hassan, I., Aung, M.M.T., Kamaruzaman, T.H.T., & Musa, R.M. (2018). Avoiding

medication errors through effective communication in a healthcare environment.

Movement Health & Exercise 7​(1) 115-128.

Taylor, R. (2016). Nurses’ perceptions of horizontal violence. ​Global Qualitative Nursing

Research.​ doi: 10.1177/2333393616641002

The Joint Commission. (2019). ​Sentinel event policy and procedures.​ Retrieved from

https://www.jointcommission.org/sentinel_event_policy_and_procedures/

The Joint Commission. (2016). Bullying has no place in health care. Retrieved from

https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_24_June_2016.pdf

The Joint Commission. (2015). Patient safety. Retrieved from

https://www.jointcommission.org/assets/1/23/jconline_April_29_15.pdf

The Joint Commission. (2011). ​Sentinel event alert.​ Retrieved from

https://www.jointcommission.org/assets/1/18/SEA_48_HCW_Fatigue_FINAL_w_2018_

addendum.pdf

The Joint Commission. (2008). ​Sentinel event alert.​ Retrieved from

http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm
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Wong, K. (2017). Fighting the effects of nurse fatigue. ​American Nurse Today.​ Advanced online

publication. Retrieved from

https://www.americannursetoday.com/fighting-effects-nurse-fatigue/