Running head: DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

Disruptive Behavior Leads to Sentinel Event

Harpreet Kaur
California State University, Stanislaus
December 12, 2014

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

Disruptive Behavior Leads to Sentinel Event

To err is human; to forgive divine (Maynard, 2006, p. 350). This famous quote by
Alexander Pope is applicable to healthcare professionals. Hospitals are meant to be one of the
safest places out of all places, but due to a rise in disruptive behaviors among healthcare workers,
it cannot be considered safe anymore. Felblinger (2009) discussed that 25 % of the nurses,
physicians, and administrators associated a connection between disruptive behaviors and patient
deaths. Nurses distressed by their co-workers showed increased non-attendance, turnover
intentions, and patient care errors (Felblinger, 2009). Among preventable errors such as falls,
fires, and suicides, medication errors seem to be escalating. These errors should not be
overlooked, but should rather serve as a topic of discussion in order to prevent further mistakes.
Disruptive behaviors among nurses and healthcare providers result in patient care errors;
in order to prevent these errors, facility members must work together to prevent hostile
working conditions.
Sentinel Event
A sentinel event is an unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof (The Joint Commission [TJC], 2012, p.1). TJC refers to
these events as sentinel because they require instant exploration and reaction. Examples of
sentinel event include: suicide, unexpected death of a full-term infant, abduction of a patient,
discharge of an infant to incorrect family, and rape or assault. After a sentinel event takes place,
the responsible hospital is expected to recognize and react to such an event through proper
incident reporting to TJC, developing an appropriate and detailed root cause analysis (RCA), and
initiating an action plan to execute improvements and decrease risks. The emphasis of RCA is
not on individual performance, but on systems and processes. Moreover, it ascertains possible

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

improvements in such systems and processes to eliminate potential hazards from striking again.
The outcome of RCA is a plan that tackles tasks associated with implementing, overlooking,
testing, and quantifying the efficiency of modifications. The hospitals must formulate RCA and
an action plan within 45 calendar days of the event, or after recognition of an event. Afterwards,
TJC decides whether or not the RCA data and the action plan are satisfactory (TJC, 2012).
Disruptive behavior
There are many disruptive behaviors that occur in hospitals on a daily basis. After
receiving her nursing licensure, Jenifer was working on the medical surgical and telemetry units
for a month, until a dream job offer of working as an ICU nurse arrived (Sanner-Stiehr & WardSmith, 2014). Jenifer was filled with enthusiasm and excitement; however, her preceptor, Vicki,
was not, as she was obligated to precept per ICU managers orders. Despite expressing her lack
of desire to precept, the manager refused. Vicki believed in exploring things on ones own and
not explaining anything. She was stressed with the short staffing, increased patient acuity, and
workload; thus, orienting a new nurse was another burden. A month passed by; oblivious of
Vickis stressors, Jenifer continued to present with an exhilaration to learn. The exhilaration
soon faded when Vicki rarely greeted her, suggested she find the answers herself, and provided
no guidance at all (Sanner-Stiehr & Ward-Smith, 2014).
On the chilly night of December 11, 2010 in Denver, Colorado, apprehensive and anxious
25-year-old Jenifer returned to work at Denver Memorial Hospital. The night started off as
usual; Vicki did not even bother saying hi to Jenifer, the morning shift nurse passed a short shift
report, and the rest of the nurses complained about their assignments. Around 2200, Jenifer
noticed that 55 year old Don Smith was scheduled to receive Nimodipine for his subarachnoid
hemorrhage. Jenifer was not familiar with the administration of this medication, but she did not

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

want to approach Vicki, due to their previously failed encounters. After taking a deep breath and
gathering some leftover hope, she walked up to Vicki while she was charting and gossiping at the
nurses station. Jenifer expressed her concern about administering the medication, but received
the dreaded answer look it up yourself and an eye roll. As she was walking towards Mr.
Smiths room, she overheard Vicki and another nurse referring to her as incompetent. Jenifer
now doubted her nursing skills and her competence in staying in the ICU setting. The selfconfidence, that she joined the ICU with, was starting to dwindle.
Nothing seemed to be in Jenifers favor; additional chaos occurred with the Electronic
Health Record (EHR) system and the Internet shut down. Jenifer knew paper charting from her
previous job; however, she was not comfortable with it. Now disappointed and overwhelmed,
Jenifer went to the sedated Mr. Smiths room and started to look up the medication in the drug
book for instructions under inadequate lighting and loud television commercials. As she was
reading, the call light next door started ringing. Noticing that no one was available to answer,
Jenifer placed the medication on the bedside table and went to see what the other patient wanted.
She looked at the clock and realized it was 2245 already. Feeling rushed, Jenifer made the
decision that would throw her in a lifelong regret. Because Mr. Smith could not swallow the
medication, she drew up 60 mg of Nimodipine from two capsules, each containing 30 mg, into
an intravenous (IV) syringe. The IV syringe is used to empty out the content in an oral syringe
and be delivered through a nasogastric tube (Shepherd, 2013); Jenifer missed this essential step.
She pushed the medication through an IV route and led the patient into a cardiac arrest. Despite
20 minutes of cardiopulmonary resuscitation and defibrillator shocks, Mr. Smith was pronounced
dead at 2330. The staff called the family members to say their final goodbyes, and three police
officers took Jenifer to the local police station for further investigation.

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

Root Cause Analysis

RCA aims to recognize revisions for fundamental systems and processes, and either
redesign them or create new systems/processes to lower the risk of them reoccurring in the future
(TJC, 2012). In order to be thorough, the analysis must ascertain that a human factor or another
factor correlated with the sentinel event; it should include a series of why questions to know
whether remodeling them may decrease risk and distinguish risk points that lead to the event.
Additionally, to be credible, the RCA must incorporate the contribution of the leaders of the
hospital and the staff who are closely working with the systems and processes. Moreover, the
RCA must be persistent by not leaving any questions unanswered, explaining all results, and
incorporating any pertinent literature (TJC, 2012).
People
Jenifer was a victim of disruptive behaviors. According to Rosenstein and ODaniels
study among 4,530 healthcare workers (as cited in Longo & Hain, 2014), 71 % reported a link
between medication error and disruptive behaviors and 27 % felt a connection with patient
mortality. However, Vicki should not be blamed for this situation. The hospital lacked
appropriate policy and training to familiarize its employees with appropriate and inappropriate
behaviors. Furthermore, the ICU manager failed to provide an explanation for selecting Vicki as
a preceptor and showed noncompliance when she complained. Vicki was overwhelmed with the
high workload, short staff, and the responsibility of orienting a new nurse. She demonstrated
frustration through her behavior with Jenifer. According to Embree and While (2010), disruptive
behaviors not only cause psychological and physical consequences, but they also result in
negative patient outcomes. In addition, nurse-to-nurse lateral violence leads to low self-esteem,
depression, self-hatred, and powerlessness (Embree & White, 2010). This proved to be true for

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

Jenifer, as she lost confidence in her skills and abilities as a nurse and made an error costing Mr.
Smith his life. On the other hand, Mr. Smith was sedated and had no family at the bedside; if he
was awake or had family around, then maybe Jenifers error to administer medication via the
wrong route could have been caught early enough and avoided.
Environment
Jenifer administered the medication under inadequate lighting and disturbances including
staff gossiping, call lights, and TV volume. Environmental factors such as poor lighting, noise,
interruption, and substantial workload often lead to medication errors (Institution for Safe
Medication Practices [ISMP], 2012). With each interruption, the risk for medication error
increases by 12.7 %. Progressing to a new task raises the risk of error with either or both tasks,
as distractions and interruptions trigger cognitive fatigue mental slip-ups, lapses, and errors.
When one remembers to finish the initial task, the whole task may need to be repeated. For
administering medication, the entire process may be restarted. Examples of interruptions include
staff, patients, visitors, computers, infusion pumps, and phones. Examples of distractions may
be overhead pagers, alarms, noises, and alerts (ISMP, 2012).
Policy/Procedures
Nurses are primarily responsible for medication administration (Hughes & Blegen, 2008).
They are accountable for both preparing and dispensing medications. About 40.9 % medications
administered through wrong dose, 16 % wrong drugs, and 9.5 % wrong routes have contributed
to medications errors causing patient deaths (Hughes & Blegen, 2008). Jenifer was responsible
for checking the six medication rights prior to administering the medication. She was
unsuccessful for assuring the right route. However, the lack of policy on labeling the IV syringe
as Not for IV use contributed to this failure. Because of this mistake, Jenifer administered the

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

medication intravenously instead of via nasogastric tube. Most importantly, Jenifer and Vicki
reacted as they did because they lacked appropriate education and training for handling
disruptive behaviors. Vicki was unaware of her role to oversee Jenifers performance; thus, she
continued acting rudely to her. On the other hand, Jenifer was not aware of the available
resources and did not know who to approach for help.
Equipment
The odds were not in Jenifers favor. The EHR system and the Internet went down at the
worst time. Usually the system starts working in few minutes, but occasionally it stays off for
few hours; that night it stayed off for three hours. Jenifer was beyond nervous; however, she
tried to remain calm and composed because she knew she was dealing with real lives. She made
an effort to properly administer Nimodipine by looking it up in the drug book. However, it
proved to be time consuming. In addition, lack of proper lighting and interruptions made it hard
for her to focus. The struggle added additional stress.
Beginning Change
The target change is designed to avert sentinel events caused by disruptive behavior
among nurses. According to Thomson (2014), stakeholders are those that are affected by or
affect the nurses work and are concerned in its outcome. Accordingly, the stakeholders in this
case are patients, hospital administration, and the hospitals chief executive officer (CEO).
Patients, being the primary customers of the healthcare services, are the main stakeholders. They
are paying for and are utilizing the health care services. Any patient is expected to be
apprehensive and hesitant due to their physical condition, but they may further deteriorate
secondary to conflicts between his or her caregivers. Nurses, the primary healthcare providers,
are the target population. They are directly involved in the care of their patients; therefore, any

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

conflict among them creates a risk in patient safety. Physically and psychologically impacted by
the disruptive behaviors, even the most skilled healthcare providers may commit an error;
therefore, they seek strategies and knowledge that can help them in ensuring patient well-being.
Finally, the hospital administration and CEO play a role as stakeholders, as they are concerned
with the hospitals reputation and may financially contribute to its betterment.
Plans for Change
Kurt Lewin, a physicist and a social scientist, developed a model called Unfreeze
Change Refreeze, which is a three-step process centered on the analogy of altering the shape of
block of ice (Mind Tools, 2014).
First Stage/ Unfreezing
According to Shirley (2013), the first step, the unfreeze stage, requires the nurse manager
to acknowledge a problem, recognize the necessity for change, and show others that necessity.
This stage includes forming a sense of urgency and developing solutions that repel against the
current norm (Shirley, 2013). In Jenifers situation, it is essential to unfreeze the situation to
show why disruptive behaviors are an issue. Additionally, it is significant to acquire tools or
ideas to reduce these behaviors, their underlying reasons, and their effects such as medication
errors and patient deaths. For recognizing the existing problem, the staff will be given a
questionnaire on disruptive behaviors. These questions will include a description of the
disruptive behaviors such as bullying, neglect, intimidation, etc., whether or not they have
experienced any of the behaviors within the last six months, and if they have been impacted
physically or psychologically as a result of these behaviors. Longo and Hain (2014) recommend
educating staff on distinguishing between appropriate and inappropriate behaviors and creating
policies on acceptable behaviors to stress intolerance for disruptive behaviors. Communication

DISRUPTIVE BEHAVIOR LEADS TO SENTINEL EVENT

is essential, because when nurses feel ignored, or realize their concerns not being heard, they will
not share their critical input necessary for future discussion (Longo & Hain, 2014). Therefore,
for preventing future incidents of lateral violence and creating a respectful environment, SannerStiehr and Ward-Smith (2014) recommend communication workshops to strengthen
interpersonal communication. Once a month, these workshops will focus on being assertive,
recognizing disruptive behavior, and practicing cognitive rehearsal; they will last 30 minutes and
will be scheduled throughout the day including the day shift and the night shift. They will be
offered three times during the day shift and twice during the night shift, so that the staff can
attend them whenever they have time. The date and times of these workshops will be posted in
the break rooms and the nurses stations throughout the hospital. Longo (2010) noted that new
nurses, using cognitive rehearsal techniques, effectively confronted the nurses who were
displaying lateral violence. Moreover, the nurse manager should reassure positive
communication through positive feedback (Sanner-Stiehr & Ward-Smith, 2014). An example
may be encouraging staff members to nominate an employee for being an employee of the
month, based on his or her positive attitude, and awarding him or her with a certificate and a gift
card. For nominations, nomination or comment boxes will be placed in the nurses stations and
break rooms.
According to Longo (2010), nurse managers may play a key role in altering their
workplace environment by assessing for disruptive behaviors through rounding similar to
physician rounding. Nurse managers may do daily rounds on their unit to address their
employees concerns and apprehensions. This way they will not only inspect disruptive
behaviors, but also recognize their employees inputs and insufficiencies in patient care (Longo,
2010).

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Nurses can help themselves and other nurses by listening to each other and expressing
emotions to reconsider the situation and prepare to confront it in future (Longo, 2010). To
accomplish this, a strategy that can be used is announcing a "Code Bully" or a "Code Pink.
This code can be called out by formal announcement or by word of mouth when witnessing
another nurse being yelled by any healthcare professional. Responding to the code, the nurses
will stand behind the victim to portray unity and discourage disruptive behavior (Longo, 2010).
Lastly, all three floors of the Denver Memorial Hospital will be provided with Not For
IV Push labels. A policy will be in place to make the use of these mandatory to prevent any
future errors.
Second Stage/Transition
The second stage, or the change or transition, looks at change as an ongoing practice
rather than an occurrence. This stage generates reactions from the individuals and a movement
to the new direction (Shirley, 2013). It is expected that some staff members may not embrace the
change or may have certain complaints regarding the change. Thus, it is important for the nurse
manager to ask for feedback during daily rounds and clear any misconceptions or speculations.
Moreover, nurses may share with other nurses any helpful tips and benefits they acquired from
communication workshops and cognitive rehearsals and encourage them to participate. With
enough individuals participating, and results becoming visible, the change can progress to the
refreeze stage.
Third Stage/Refreezing
The third stage, or the refreezing step, is about cementing the changes for making them a
part of the current system including practices and policy and procedures. Refreezing the new
changes, the ongoing process now becomes the new norm or expectation (Shirley, 2013). In this

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stage, the nurses will be communicating effectively and avoiding any disruptive behaviors. They
will be utilizing the techniques they learned from the communication workshops. Furthermore,
they will show a healthy competition for earning the Employee of the Month award. In
addition, the nurse manager will continue to do daily rounds and seek suggestions for enhancing
the new changes and fixing any hurdles against them.
Attitudes and Unanticipated Consequences
Its possible that some nurses may not realize that their behavior is coming across as
disruptive (Longo, 2010). In such cases, the nurse manager may review other staff members
views with a particular nurse and should offer resources to help resolve the underlying cause of
the behavior. In addition, to ease the frustration, the manager needs to ensure the victims of
these behaviors that actions are being taken to rectify the errors, while patient confidentiality is
maintained (Longo, 2010). Zero tolerance policy will be enforced for the nurses who continue to
display disruptive behavior and are non- compliant with communication workshops. In addition
to zero tolerance policy, American Bar Association (as cited in Martin, 2008) suggests a five step
disciplinary process that progresses from verbal warning to authorities action if the behavior
persists.
Budget
Following action plan, a budget will be constructed to determine costs for implementing
changes to prevent sentinel events related to disruptive behaviors. The new budget will be
$1505. It will include questionnaires on disruptive behaviors, communication workshops,
comment or nomination boxes, gifts cards, and NOT FOR IV USE labels. The price is fairly
reasonable compared to a family losing a loved one and the employees facing an emotional
crisis.

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The hospitals aim to provide safe and effective care for the patients; however, the care is
often impeded due to sentinel events especially disruptive behaviors. Thus, it is essential to
identify potential hurdles through RCA and to implement alterations and modifications through
an action plan. For finding solutions and seeking guidance, the hospitals may explore evidence
based literature and Lewins Unfreeze-Change-Refreeze model. The change will not take effect
in a moment; it will be an ongoing process. The hospital personnel must work together to keep
each other engaged towards achieving the goal and be prepared for any unexpected outcomes.

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Budget for ReducingDisruptiveBehaviors

Year:

2014

Organization: Denver Memorial Hospital

Submitted by: Harpreet Kaur

Line
Item
1 Questionnaire on disruptive behaviors

2 Communication workshops

3 Comment/Nomintion Boxes

4 Gift Cards

5 "Not for IV Push" labels

Total Budget:
$1,505
Budget Planning
Description/Justifcation
Qty. Unit Cost/Rate
Total
These questionnaires will be used for conducting a study to
50
$1
$50
explore the need for change. The ICU manager will print out
the questionnaires and distribute them among the nurses.
Once a month, in these workshops, the nurse educator will
1
$1,200
$1,200
teach about being assertive, recognizing disruptive behaviors,
and practicing cognitive rehearsal techniques through
interactive tasks. These workshops will be paid and count as
CEUs (Nurse educator- 40 hr X 5 classes lasting 30 minutes =
$100, 50 nurses X 30 minutes or $20 = $1000) (Handouts and
information materials for 50 nurses = $100)
These boxes will be available for the staff members to leave
6
$20
$120
any suggestions and inputs about the current or possible
changes. Additionally, they can nominate an employee each
month for "Employee of the Month" (2 boxes X 3 floor = 12
boxes)
These gift cards for local stores will serve as a token of
12
$10
$120
appreciation. They will encourage the nurses to continue the
positive behaviors.
These labels will ensure that the IV syringes are used for
3
$5
$15
transferring medications from Nimodipine capsules to oral
syringes and not for IV push. (3 floors X 5 dollar valule for
each package containing 1000 labels)
Grand Total $1,505

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