Systems errors


Systems errors, human errors, and process issues can lead to sentinel events in a hospital. Create your initial post and then use the response prompts to reply to the scenarios or examples created by at least two peers.

Initial Post

In 200–250 words, construct a scenario or example of an error that would result in harm to a patient for your initial post. This scenario or example can be something you have witnessed or a hypothetical example of a sentinel event. DO NOT post the same scenario or example as a peer.


How Did Organizational Influence Unsafe Supervision Etc. Cause This Error To Happen? How Will You Avoid Making Such An Error In The Future?

Systems errors

Scenario: A patient with a severe peanut allergy is admitted to a hospital. Despite the patient’s allergy being clearly documented in their medical record, the nursing staff inadvertently administers a medication that contains peanut oil. The patient has a severe allergic reaction, requiring emergency treatment and prolonged hospitalization.

This scenario demonstrates how a systems error, specifically a breakdown in communication and documentation, can lead to a sentinel event. In this case, the failure to properly communicate the patient’s allergy status and ensure that all medical staff are aware of it led to the administration of a medication that caused harm.

Organizational influence and unsafe supervision may have contributed to this error by failing to provide adequate training and resources for staff to ensure that patient allergies are consistently and accurately documented, and that this information is shared across all departments and shifts.

To avoid making such an error in the future, healthcare providers should prioritize effective communication and documentation processes to ensure that important patient information, such as allergies, is accurately recorded and shared with all relevant staff. This can be achieved through the use of electronic medical records and standardized protocols for documenting allergies and other medical conditions. Additionally, ongoing training and education for staff on the importance of accurate documentation and communication can help prevent similar errors from occurring in the future.

Scroll to Top