Understanding What Happened

1. What happened? Begin by understanding the sequence of events leading up to the sentinel event. Gather detailed information about the incident, including the timeline, people involved, and context.

o Who did the problem/event affect, and how?

The sentinel event affected the patient the most of all as he experienced the most severe cardiac complications, cardiac arrest, and a prolonged period of stay at the ICU due to the inability to diagnose the initial warning signs of myocardial infarction and provide the patient with the necessary treatment, and pneumonia. This had contributed to delayed agony, higher treatment costs, and delayed recovery. The relatives of the suffering patient were emotionally shocked and had no more confidence in the health care system, but the ICU medical personnel had to encounter moral traumas, stress, and fear of being sued because of the error. The medical facility also suffered because of its reputation, increased financial burden, and the possibility of malpractice suits (Hall et al., 2020).

2. Why did it happen?:

o Human Factors: Investigate whether communication breakdowns, staff fatigue, or lack of training contributed.

o System Factors: Examine workflow processes, equipment failures, and environmental factors.

o Organizational Culture: Assess if there are cultural issues, a lack of safety culture, or inadequate leadership support.

o Society/Culture: What role might cultural assumptions or backgrounds play?

The reasons behind the sentinel event were human factors, system issues, organizational culture, and societal pressures. The cognitive factors (anchoring and premature closure) predisposed the physician to make a premature diagnosis of pneumonia and not take into account the causes of cardiac origin. The lab reports were inconsistent, and the nurse was so overworked and exhausted that she did not develop abnormal results so soon. System-related problems (disjointed electronic health records, delays in lab and ECG results, absence of automated critical values notification) and inconsistent documentation in case of a change of shifts led to the emergence of information gaps that postponed the delivery of lab and ECG findings (Prior et al., 2023). The ICU had quite a task-oriented culture, where rapid interventions were primarily concentrated on the most obviously critical cases and did not focus much on the diagnostic review, second opinions, and effective leadership of the diagnostic safety (Dietl et al., 2023). Further, due to a high patient count and the societal expectations to offer rapid diagnoses, clinicians were overwhelmed with the responsibility of having to make quick decisions and not necessarily focus on alternative causes (Balogh et al., 2019).

3. Was there a deviation from protocols or standards?:

o Procedures and Policies: Determine if established protocols were followed or if there were deviations.

o Were there any steps that were not taken or did not happen as intended?

o Documentation: Review medical records, nursing notes, and other relevant documentation.

Yes. According to the rules of the Joint Commission and Agency of Healthcare Research and Quality (AHRQ), one should receive the results of diagnostic tests as fast as possible and respond to atypical test values promptly. However, the closed-loop communication of the troponin results was not present, and delivering shifts with standardized SBAR reporting was not utilized. The best practices were not observed since reviewing checklists was not done (Khafaji et al., 2022). Early warning signs records were also incomplete, and this also delayed the observation of the cardiac event.

4. Who was involved?:

o Staff: Identify the roles of individuals directly involved in the event.

o Supervisors and Managers: Investigate

Staff: Direct engagement was with an attending physician who did the initial diagnosis and an ICU nurse who was monitoring the patient.

Supervisors and Managers: The nurses and ICU supervisors were also not present since they failed to staff and survey the quality of the handovers appropriately.

Ancillary Staff: ECG and laboratory technicians generated the data but did not have an avenue for relaying any vital values to clinicians.

Leadership: The quality and safety officers failed to bring in the diagnostic decision support and compliance with communication criteria.

5. Was there a breakdown in communication?:

o Interdisciplinary Communication: Assess how well different teams communicated.

o Patient-Provider Communication: Explore whether patients were informed and understood their care.

Yes. The interdisciplinary communication between shifts was lacking – the abnormal information at the lab, and the ECG were not discussed. Its communication was not in a loop since the nurse believed that the doctor would have realized the outcomes, whereas the doctor assumed that all things in the lab were okay. This aligns with the results of Assessment 1 that proved that communication and failure to take the test are very common among the reasons that may result in misdiagnosis (Dietl et al., 2023). The degree of communication between the patient and the provider was also not so high; the family and the patient were not aware of the tests to be conducted, so they could not make the argument in their favour.

6. What were the contributing factors?:

o Physical Environment: Consider facility layout, equipment availability, and workspaces.

o Staffing Levels: Evaluate if staffing was adequate.

7. Training and Competency: Assess staff’s knowledge and skills.

Physical Environment: The busy ICU layout distracted the attention of the staff, distracting them, creating noise, and a lack of a convenient working environment to check test outcomes and compose a more detailed diagnostic argument.

Staffing Levels: The pandemic understaffing helped to create an overload and exhaustion among the staff and limited the time needed to perform diagnostic review and cooperation (Prior et al., 2023).

Training and Competency: Khafaji et al. (2022) found that employees lacked refresher training on the symptoms of early MI and systematic diagnosis thinking.

8. Did organizational policies or procedures play a role?:

o Policy Compliance: Investigate if policies were followed.

o Policy Clarity: Assess if policies are clear and accessible.

Yes. There was no policy in the organization that required the closed-loop communication feature of abnormal test results, and organized SBAR handovers were not witnessed. The policies of diagnostic safety were paper-based, but no implementation and monitoring of the same took place. This gap also corresponds to the information that diagnostic error is also a contributor that is related to lax policy enforcement (Hall et al., 2020).

9. Was there a failure in monitoring or surveillance?:

o Vital Signs Monitoring: Check if there were any missed signs.

o Alarm Fatigue: Explore if alarms were ignored.

Yes. The deviant vitals and lab findings of the patient were not adhered to and monitored in real time. The realization of the worsening trends was impeded by alert fatigue and high workloads, which aligns with the findings that ineffective surveillance systems are connected with delayed diagnosis (Vally et al., 2023).

10. What can be learned to prevent recurrence?

o Lessons Learned: Identify systemic changes, training needs, and improvement opportunities.

o Quality Improvement: Consider implementing preventive measures.

Among the lessons, the following ones are among the most crucial: structured diagnostic checklists, decision-support tools, closed-loop communication protocols, and automated notifications of critical values must be introduced. Multidisciplinary diagnostic huddles should be instituted in an attempt to look at complex cases. Staff members will be trained in cognitive debiasing and early symptom recognition, which will enhance a more accurate diagnosis. The development of a culture of feedback and learning about diagnostic near-misses will also reduce the risks (Kobrai-Abkenar et al., 2024).

11. How can patient safety be enhanced?:

o Risk Mitigation: Develop strategies to minimize risks.

o Education and Training: Ensure staff are well-trained.

12. Reporting and Feedback: Encourage open reporting and learning from mistakes.

The specified measures to enhance patient safety can be implemented in the risk mitigation, education, and feedback systems domains. The installation of automated alert systems (in case of abnormal results), structured SBAR, handover, and the implementation of diagnostic safety checklists into daily practice would reduce the risk. The training and education should be carried out in order to get the clinicians more aware of the cognitive biases, enhanced capability to recognize the symptoms of early myocardial infarction, and their capacity to be able to reason in a systematic form of diagnosis. Furthermore, the diagnostic error reporting systems and feedback loop can be adopted to provide clinicians with the possibility to learn about the missed diagnosis and continually improve the diagnostic accuracy (Agency for Healthcare Research and Quality, 2025).

Root Cause– themost basic reason that the situation occurred

Contributing Factors – additional reason(s) that clearly made a situation turn out less than ideal

HFC

HF T

HF

F/S

E

R

B

1

Absence of communication of abnormal results of troponin/ECG is due to the absence of closed-loop communication.

HF-C

2

The doctor was burdened with a diagnosis of pneumonia and could not re-examine it when there was some opposing information.

HF-T

3

The nurse did not create warning signs due to work overload and exhaustion.

HF-F/S

4

None to provide an automated alert or a built-in system to indicate critical results.

E

5

Lack of standardized SBAR handover and policy implementation that is not understood.

R

6

The culture had low status on diagnostic review or second opinions.

B

The evidence-based practice to address diagnostic errors and cognitive bias includes handover strategies that are designed to include Situation-Background-Assessment-Recommendation (SBAR), closed-loop communication to convey critical written outcomes, and multidisciplinary diagnostic huddles (Khafaji et al., 2022). EHR abnormal lab alerts are automatic to promote timely identification (Prior et al., 2023). Feedback systems can provide clinicians with a chance to learn the lesson of using mistakes in diagnostic performance (Balogh et al., 2020). These would be directly applied to human, system, and communication failures that lead to this sentinel event.

The proposed evidence-based recommendations are integrable in order to prevent such an incident as the occurrence of a diagnostic error, as the sentinel event in question. Closed-loop communication and the application of structured SBAR handovers will ensure the identification of all abnormal test outcomes (i. e., troponin elevations or ECG changes), their discussion, and documentation before the shift change and prevent the information loss. The cardiac causes will be memorized in the decision-support tools and diagnostic checklists included in the EHR, and can motivate clinicians to consider cardiac causes when patients have overlapping symptoms, such as chest discomfort and fatigue, and help in removing cognitive biases, such as anchoring. To prevent an untimely detection of abnormal results, EHR notifications will facilitate the timely detection of dangerous laboratory or ECG values by an automated system to provide the care team with an opportunity to intervene in time. The teams will be empowered to review near-misses and patterns and the idea of error education in order to improve clinical reasoning at the group level through multidisciplinary diagnostic review huddles and feedback systems. Lastly, the power of clinicians to recognize the high-risk cases early enough and avoid premature closure will be enhanced with the help of the refresher training on the measures of cognitive bias mitigation and early MI symptoms. The application of these strategies will address the communication, system, and human factors that caused the missed myocardial infarction in the case under study and ultimately improve the diagnostic safety and outcome of the patients.

Action Plan

One for each Root Cause/Contributing Factor from above

E / C / A

Choose one

1

Closed-loop communication and SBAR-based structured handovers will be implemented to avoid the loss of results.

C

2

Offer early warning signs of MI, reduction of cognitive bias, and diagnostic reasoning refresher training.

C

3

Install automated EHR notifications on important lab/ECG findings.

E

4

Hold routinely scheduled diagnostic huddles and peer feedback to discuss missed cases.

A

The organization will aim at introducing several specialized processes and development programs to alleviate the underlying causes of the diagnostic errors. Categorical policies will be ready to subject closed-loop communication to all the various meaningful outcomes of the diagnosis to ensure the abnormal findings are identified, escalated, and recorded within due time. All clinical units will be introduced to formal SBAR handover routines to transfer the patient information in a uniform way and prevent omissions in the shift-to-shift transfers. In addition, the quarterly diagnostic safety education and simulation activities will be introduced to enhance the staff’s competence in the skills of detecting the first symptoms of myocardial infarction, applying systematized diagnostic reasoning, and decreasing the influence of cognitive biases. Furthermore, a formal reporting and feedback system of the diagnostic errors will be established, in accordance with which the staff members will report near-misses and get constructive feedback that will help them increase their diagnostic decision-making abilities even further.

The general aim of these interventions is to reduce the errors in diagnoses and enhance interdisciplinary communication, and enhance patient safety outcomes. It will be implemented in stages that will be effective and lasting. Months one and two will be spent on the development of succinct policies, the creation of structured SBAR handovers, and the installation of EHR-dependent alerts regarding vital diagnostic values. The third and fourth months will be allocated to the personnel training on the identification of myocardial infarction, the decrease of cognitive bias, and systematic diagnostic thinking. The new reporting and feedback systems and multidisciplinary diagnostic huddles will be introduced in the fifth to sixth month to improve real-time collaboration and learning. These interventions will be maintained since the seventh month onwards, with the perpetuation of such interventions through continued monitoring and regular feedback meetings, and cultural programs, which will guarantee the long-term commitment to diagnostic safety across the entire organization.

EHR infrastructure can support alert systems with a new one. Quality and safety departments can brainstorm about policy and monitor their compliance. Harding clinicians are able to employ peer mentorship during the diagnostic huddles. The educational departments can carry out simulations and frequent training. It will assist in safe and sustainable implementation when the resources are used.