PTCB Certified Pharmacy Technician (PTCE)Patient Safety and Quality AssuranceMedium
Which of the following is an example of a 'sentinel event' in a pharmacy setting?
- AA technician misfiles a patient's insurance information.
- BA pharmacy experiences a temporary outage of its computer system.
- CA patient receives the wrong medication and experiences a fatal allergic reaction.
- DA pharmacist discovers a dispensing error before the medication leaves the pharmacy.
Show answer & explanationAnswer & explanation
Correct answer: C. A patient receives the wrong medication and experiences a fatal allergic reaction.
A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. A fatal allergic reaction due to a medication error unequivocally fits this definition, triggering a mandatory review and investigation.
Why the other options are wrong
- A. Misfiling insurance information is an administrative error, not a sentinel event.
- B. A computer system outage is an operational disruption, not a sentinel event related to patient harm.
- D. Discovering an error before it reaches the patient is a 'near miss' or 'good catch,' which is positive for patient safety, not a sentinel event.
Sentinel Event
An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
- Requires immediate investigation (Root Cause Analysis) by the organization.
- Alerts the need for immediate response and investigation.
- Examples: wrong-site surgery, suicide in a healthcare facility, fatal medication error.
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