Here, the administrator can arrange for nurse education and awareness creation on the need to maintain proper hand washing habits in the unit. In the case, it is evident that both human error and institutional factors are to blame.Īfter identifying the root causes, it should be the administrator’s role to lead in the development and implementation of policies and strategies that will reinforce effective communication and compliance with proper infection prevention techniques at the unit level. Such a survey is likely to identify the proximal root causes of the identified barriers and help in determining if the root causes are related to human error or institutional factors such as poor implementation of procedures and policies. For example, the administrator can use her position to solicit for funds to be used in undertaking a comprehensive survey on service provision and quality care indicators within the unit. As a leader, it is the role of the nurse administrator to develop strategies and approaches that will break down the barriers to identify their root causes. The root cause analysis is described as “a systematic process used to address problems or non-conformance to identify the source of the problem” (Connelly, 2012, p. The Nursing administrator can use the root cause analysis to identify and correct the barriers that caused the sentinel event. Indeed, health professionals and visitors to the hospital are required to wash their hands or use hygienic hand disinfection after coming into contact with patients regardless of whether gloves are used or not. Available literature underscores the importance of proper hand hygiene in preventing the transfer of nosocomial infections (Garus-Pakowska, Sobala, & Szatko, 2013). Additionally, while most hospitals do not allow young children to visit post-op wards due the high probability of getting hospital infections such as MRSA (Chowers, Carmeli, Shitrit, Eihayany, & Geffen, 2015), it is clear that this practice was not followed in this particular case as the family member was allowed to visit her father with a young boy who was sick with flu. This barrier led to the transfer of MRSA from the male patient to the female patient through poor hand washing habits. In healthcare practices, it is evident that the unit did not follow proper infection prevention strategies particularly with regard to hand washing and use of gloves. This barrier in communication could be as a result of factors such as nurse workload demands, insufficient time, lack of clear policies on how to raise complaints and concerns, ignorance, and attitudinal problems (Hemsley, Balandin, & Worrall, 2012). Also, a nurse who had observed the family member exit the patient’s room with gloves failed to communicate that it was against the unit’s infection prevention protocols to move around with unclean gloves. In communication, it is clear that the family member who was visiting her father in the post-op unit failed to report her observations on poor infection control measures and noncompliance with hospital protocols even after having the knowledge that the surgical resident failed to follow proper hand washing techniques. Barriers in Communication and Healthcare Practices The young female patient ultimately died of MRSA even though she had been admitted to the unit due to the appendectomy. It is also reported how the family member took her young child to the hospital to visit her father despite the boy being sick with flu. Earlier, the visitor had observed a resident professional assessing her father twice without following proper hand washing techniques but failed to report this incident to the relevant authorities. As demonstrated in the case, the father had a surgical wound that was infected with MRSA.

The MRSA pathogens had been transferred to the counter by a visitor who was taking care of her father in the post-op unit. The patient was exposed to MRSA through a nurse who came into contact with the pathogens due to failure to follow hospital protocols on gloves use and hand washing. The sentinel event revolves around a young female patient who contracted MRSA at the post-op unit, where she was being observed after a successful appendectomy.

Nurse sentinel event