Sentinel Event

By: Delilah




This is just a silly little piece written after being bombarded by e-mail after e-mail reminding me to remember the definition of "Sentinel Event" in case the Hospital Joint Commission inspection guys got a hold of me -- as I work ten miles from the hospital itself, this was a little doubtful. Thanks to Lyn for looking it over for me.


Emergency rooms. They’re pretty much the same in Miami, Topeka or Cascade, Washington. Try keeping a team of trauma nurses working at their peak in any of them. That’s not to mention the complexities of keeping qualified staff at a couple of small, rural hospitals in unpopulated Idaho. So, Shannon Reed had seen it all. Or thought she had, though as she turned the pages of the Cascade General ER's dog-eared binder she began to think she just might have been wrong.

"Uh, Melinda."

Melinda Sherwood seemed to be as good a trauma nurse as they came, unlikely to be part of some ritual hazing of the Emergency Department's new head RN.

"This is surely a joke, right? I mean I understand some places tease the new guy, but Joint Commission is not something to be kidding with."

The dark eyes gazing at her from beneath Melinda's neat braids narrowed in confusion before she looked down at the notebook's open page and a smile spread. "That's the Sentinel Event book."

"I know." Shannon tried her best stern look. "And I really don't think it's something to be messing with."

"We didn't," protested the trauma nurse.

"Read this definition then, and tell me there's not something wrong."

Melinda complied, rarely glancing at the page. "A Sentinel Event is an unexpected occurrence involving the death or serious physical or psychological injury of the guide, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase 'or the risk thereof' includes any process variations for which a recurrence would carry a significant chance of serious adverse outcome from the sentinel."

The woman was good, Shannon had to admit that. She'd kept a straight face. In fact, she looked completely serious. "And you don't see anything wrong with that?"

"Uh, you've been here three days, right?"

Shannon nodded. "Right."

Melinda gave her hand a little pat. "Give it a couple of days. Once you see a Sentinel Event, you'll understand."

"I certainly hope not!" Shannon was rapidly losing her amusement. Seventeen years and she'd never had to report a Sentinel Event. She certainly didn't plan on having to report one here. It'd been hell surviving the last month at her last hospital. JCAHO survey tips posted everywhere. Constant perky e-mails saying "Do you know what to do when there's a fire? Just remember RACE CAR!" They'd crawled through the Sentinel Event binder until every last person down to the ER registration clerks could repeat it verbatim. Coming in to find this kind of disarray ...

"Well, you do know what to do, don’t you?" inquired Melinda, interrupting her thoughts on getting the hell out of Cascade while she still had her licensure intact.

Shannon blinked. "Level One Trauma Center," her ass. Who the hell had been training these people? At this rate they'd be lucky to keep accreditation as an outpatient surgery center.

"Of course, it's standard procedure pretty much nationwide. Immediately inform your supervisor and/or Administrative Supervisor, complete an Administrative Report, and secure any evidence in the patient area. Conduct a thorough and credible Root Cause Analysis."

"Okay …" Melinda sounded somewhat doubtful as she flipped to the back of the book. "And here are the Root Cause Analyses of *our* last twenty-two Sentinel Events."

Shannon’s lungs seriously pondered hyperventilating. *Twenty-two* Sentinel Events? And the place wasn’t shut down? One eye practically closed, like if she only glanced at it she couldn’t be blamed, Shannon peeked hesitantly at the report.



Sentinel Event: Ellison (sentinel) insisted on carrying semi-conscious Sandburg (guide) from ambulance to treatment room #3. Refused to leave room when requested.

Root cause: Sentinel upset by kidnapping of guide by serial killer David Lash, who was brought DOA to treatment room #5. Cause of death determined to be multiple shots from sentinel's gun.


Okay … that was … odd. She flipped further toward the middle.



Sentinel Event: Despite obvious visual impairment, Ellison (sentinel) refused existence or treatment of injury, insisting on remaining by side of Sandburg (guide) who was brought in for treatment of respiratory depression and coma resulting from accidental ingestion of Golden.

Root cause: Root cause of sentinel's injury was never determined. Sentinel was allowed to remain by guide's side. Extra staff was assigned to observe Sentinel at a distance for safety of both. Root cause of guide's injury was deliberate poisoning by individuals whom sentinel was investigating.


Either this was the most elaborate hazing she'd ever seen or these people were nuts. Cracked. The patients on the psych floor had obviously escaped and were masquerading as Cascade General's ER staff.

"They're coming!"

Shannon put down the binder and watched as one of the ER residents nearly knocked down a lab tech and two of the more burly guys from the transport pool in his hurry to get to the nurses' station phone. He snatched the receiver up, stabbed the "0" and hurriedly barked for the head resident AOD to be paged stat.

Beside him, Carmen Suarez, the physician practitioner, was punching up optical medical records.

"They're behind again," she muttered tightly, waving a hand toward the screen while the other settled on her hip. "You'd think they could manage to code and scan to optical in ten days."

Carmen looked past Shannon to Melinda, "How many days ago were they in here? It was last week, right?"

Melinda bit her lower lip in concentration. "Last time was just a graze. Taped up and we were done."

"Let's hope it's that easy," sighed Carmen, refixing her focus on Shannon. "It's probably your first time, huh?"

"To handle a trauma? No, I came from a Level I teaching—"

Shannon didn't get to finish as the ambulance bay doors slammed open and the EMTs noisily rushed in with a gurney. Melinda and the resident disappeared into Trauma Two while Carmen shoved a clipboard full of admission forms in Shannon's direction.

"Give those to the captain. He's the tall, dark, good-looking one in the suit. The sentinel won't be calm enough to fill them out." The pract grinned. "You're nursing director, that means you get to handle Ellison."

Shannon frowned. Had she just said "Ellison"? Wasn't the binder all about some guy with that name?

"Ten o'clock and closing." Carmen smiled sweetly, putting her hands on her newest coworker's shoulders.

"Huh?" murmured Shannon as she found herself turned one-eighty to face the most staggering pair of blue eyes she'd ever seen.

"Um," she gulped.

The incredible blue eyes dismissed her as inconsequential and moved on to Suarez.

"No," said Carmen, shaking her finger at the man towering over her. "You know the rules. Sit down and be a good boy, and Ms. Reed here will let you in as soon as possible."

Carmen wrestled the clipboard from fingers rapidly going numb and presented it to the tall, suited man, flashing the smile she usually saved for Dr. Bajepalli. "Captain, you know the drill."

She turned back to Blue-Eyes. "Sit."

He distinctly didn't.

Shannon blinked bewilderedly when Carmen leaned in to whisper; "The longer you can keep him out here, the quicker they'll get done in there. But if he has to go in, don't stop him."

Shannon gulped again. "How will I know if he has to go in?"

Carmen headed to join the chaos of the trauma room. "Oh, you'll know."

Rural Idaho really hadn't been that bad, had it? Shannon tried to remember as she stood, arms crossed, guarding the number two trauma room from … Blue Eyes. She heard the usual cacophony but nothing that had her too worried at the moment. GSW, but it was a through-and-through. O-neg was hung. O2 was going. BP and pulse weren't bad, considering. She could hear Melinda's soft voice coaxing the patient to stay calm.

"You've been here before, Blair, you know what to do."

"Where's J'm?"

This last was so soft, even right outside the door Shannon could barely hear it, but Blue-Eyes shot up from the bench down the hall that tall-dark-and-good-looking had practically frog-marched him to and came striding down the corridor, straight for her. Or, rather, straight for the door she was blocking.

"Think I'll just assume this is a have-to-go-in moment," murmured Shannon, quickly stepping out of the way, then stepping back to peer into the suddenly silent room.

Dr. Mosier used one hand to stop the rampaging stride and the other to motion the others from around the bed.

"He's fine. We're going to do a little surgery to close the wound. You can take him home in a couple of days."

Blue-Eyes nodded, although he looked unconvinced. "His heartbeat's awfully fast."

Kristy Mosier released his arm with a little pat. "Well, I think you know what'll fix that. We'll give you a few minutes before we take him upstairs."

The doctor waved the others out. She gave the new nursing director a look that Shannon couldn't quite read. "Keep an eye on them," she finally said when it was obvious Shannon didn't know what she wanted. "Everything should be fine."

Blue-Eyes looked once toward the door, clearly realizing he had an audience, and just as clearly not caring. He bent over the man on the gurney.

"Hey, Chief, how many times do I have to tell you that I'm the superhero around here?"

Shannon repositioned herself so she could see the injured man as he turned toward his visitor. Curly, dark hair. Gorgeous eyes made darker by the dilating effects of the drugs he'd been given. A weak smile on the full lips.

"Should have zagged," he whispered.

"Should have stayed in the truck."

"Don't have to stay in the truck any more." Shannon could tell he was rapidly losing his fight against the painkillers. "I'm your partner."

Eyelids fluttered against pale skin but the patient rallied again. "You were awfully close when he fired. Dials okay?"

Blue-eyes leaned down again, a hand gently caressing a blood-spattered cheek. "Dials are just fine. You rest now."

A hand was moved to brush a wayward curl off the pale forehead.

"Stay, J'm."

"I will, Chief, always."

When they came to wheel the patient to OR Blue-eyes gave a final squeeze to the lax hand. And as he passed her coming out the door, Blue-Eyes smiled slightly.


"Well, that was an easy one." Melinda was cradling the ratty, red binder in her arms. "You want to be the one to write it up?"

"That was a –"

"Sentinel Event," finished Melinda. "A really easy one actually. We've got him pretty well trained now and Kristy Mosier's been miles better than Dr. MacNeil used to be. Not that we were all that upset to see him airborne across the waiting room."

"He threw a doctor, across--" Shannon frowned at the spacious open waiting area. "*All* the way across?"

"Nearly broke the fish tank."


"So, you want to write it up?"

"No, please go ahead." Shannon watched Melinda start a Root Analysis form. "So, Blue-Eyes, he's a ... sentinel?"

"And Blair's his guide."

"Blair is--"

"Yep, curly hair, lips to die for."

"And they're--"

"Partners." Melinda looked up from her scribbling. "Police partners."

Carmen made a little humming sigh as she watched the tall police captain usher Blue-eyes out of the waiting area.

Melinda sighed just as wistfully. "Tell me about it, honey."

She turned a sly smile on Shannon. "So now that you've experienced one, you'll be ready for next time."

Shannon gulped louder. "Next time?"

Nope, rural Idaho hadn’t been that bad at all.