Scenario: – It was 1:55 a.m., and

Scenario: – It was 1:55 a.m., and Felix “Kirk” McDermott was struggling to breathe. He was cold and clammy. A doctor called to his bedside at the Veterans Affairs hospital in Clarksburg, West Virginia, noted white foam oozing from the 82-year-old’s mouth and a crackling sound coming from his lungs. McDermott’s heart was racing; his pupils were pinpoint. Seemingly out of the blue, the Vietnam veteran’s blood sugar had plummeted dangerously – to one-sixth the level that triggers urgent treatment, medical records show. That dramatic decline could have been a significant clue, since McDermott was not diabetic. But it was not recognized as such in the early morning hours of April 9, 2018. Family members said investigators told them they are focusing on a person of interest who may have killed as many as 10 patients in 11 months by injecting them with insulin. Hospital spokesman Wesley Walls said officials notified authorities “immediately upon discovering these serious allegations” and put “safeguards in place to ensure the safety of each and every one of our patients.” The person has been removed from patient care. Questions: 1. Why is this event considered a “sentinel event”? 2. What role does risk management play in making sure nurses provide safe care? 3. What is the cause -and-effect analysis on this event (check page 169 in textbook) 4. What are the key questions that need to be asked as part of the quality improvement process, to make sure this type of event never happens again? 5. What should the nurse manager and/or nursing staff have done in this situation since this type of patient death was not the first occurrence? SCIENCE HEALTH SCIENCE NURSING NURSING 123

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