Brief And Factual Review Of Sentinel Events

1. Introduction including a brief & factual review of the medical error or sentinel event. (References used to depict the source of information obtained.)

a. Anesthesia Awareness is devastating as well as putting a toll on anyone’s life. This is a rare condition in which a patient wakes up during surgery and can recall their surroundings or events that have taken place.

b. This horrific experience occurs when a patient is given medications intended to cause unconsciousness and relieve pain. These medications can fail all together or maybe just one. Therefore, a patient may become awake, feel pain, or even move, but in worse cases the patient may be able to be awake as well as feel pain but the paralytic medication does not wear off.

c. The

The problem of this sentinel event is that a patient was awake during her sugery, and was actually able to feel the surgeons working on her on the table. The patient may have came out alive, and stable, but the patients mental state will never be the same. This event has left this patient scarred for life, and may even keep her away from the operating room even if its life or death. There was a lack of skill, and education when putting the patient under, and maybe even a lack of care when administering the sedative medications. The anestheologist should have done a more thorough check to make sure the medications worked, and checked his/her calculations to be sure they will last the length of the

I believe brain monitoring systems, monitoring depth of anesthesia, more focus on HR/BP, and awaekfulness. I believe if we had a healthcare professional solely focus on the vital signs, and awakefullness of the patient they could catch a patient waking up mid-procedure quicker. This would allow for the surgeon to stop what they are doing, and let the anesthesiologist recheck the meds and decide whether they should give more, or not. Keeping a better eye on the patient’s vital signs will let us know if the patient is in distress, because their heart rate, and blood pressure may begin to slowly rise once they realize what is going