Running head: SENTINEL EVENT

Lateral Violence: A Factor in a Sentinel Event

Arnulfo Velasquez
California State University, Stanislaus

SENTINEL EVENT

Lateral Violence: A Factor in a Sentinel Event

Having a loved one die earlier than expected is something that invokes emotions in every
human being. It is something that is extremely difficult to understand, and this is what the Gray
family has been struggling with for a couple of years now. Rachel Anne Gray, an only child, was
lost in the occurrence of a sentinel event. This successful 24 year old had just graduated with her
Masters Degree in business and, without a doubt, had a bright and beautiful future ahead of her.
This Future never came. Her life ended on October 27, 2012. Her death may have been avoided
if the medical team would have worked well together. It is essential that change occurs to avoid
situations like this. An action plan has been developed using a change model to ensure this issue
does not take place again in this facility. Deaths that occur due to lack of communication
between the medical team can be avoided, and it was a tragedy that lateral violence
between the nurses in the emergency department was the main factor in causing a sentinel
event and losing such a precious life.
Many people confuse a sentinel event with just any error that is made in a medical
setting. That is a common misconception. A sentinel event can easily be caused by an error, but
not every error can be considered to be a sentinel event (The Joint Commission, 2012, p.1). For
example, if a nurse pushed her medication faster than it was indicated and the patient became
just nauseous this would be considered an error, but not a sentinel event. A situation can only be
considered a sentinel event if it was not expected and it caused significant physical or
psychological harm or death, or risk thereof (The Joint Commission, 2012, p.1). When
considering harm, it specifically refers to a loss of limb or function. The phrase or the risk
thereof includes any process variation for which a recurrence would carry a significant chance
of a serious adverse outcome (The Joint Commission, 2012, p.1). These situations are named

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sentinel events due to the need for an investigation and rapid response (The Joint Commission,
2012, p.1).
Jenny was a new nurse in the emergency department and was struggling significantly
with working together with her colleagues. During her two month orientation period, she was
often ignored and abused verbally. Her ten years of experience did not do her any good in
attempting to get comfortable in her new department. She was a new face in the emergency
department and was criticized as if she had just graduated from nursing school. Jenny would try
to be polite and say hello to her co-workers and they flat out would not reply. Sharon, another
emergency department nurse, seemed to have it in for her. One day in particular, Sharon was
laughing while talking with another nurse. Jenny walked up to them, and they suddenly became
silent. When she asked them what they were laughing about, Sharon rolled her eyes and
mumbled something to the other nurse as they turned their backs and walked away. The next day
Jenny was working with Sharon once again. During her shift she didnt want to go to lunch
because she thought a patient might have an internal bleed. She approached the doctor with her
concern and the doctor told her she must be mistaken because he had just been there ten minutes
prior and looked okay to him. Jenny suggested lab work and was waiting for the results to make
sure the doctor was alerted of any abnormal values. Sharon encouraged to her to go to lunch and
promised to watch for the results. While off the floor, Jenny heard a code called in ED. When
she got back, her patient was being rushed to the operating room. The patient did not make it out
alive from the operating room. The doctor was angry with her for not reporting the critical lab
values right away. Sharon had been notified of the lab results fifteen minutes prior, but said The
lab just called a minute ago. Jenny saw her half smile and shoulder shrug to the unit
coordinator. Jenny definitely wondered if she was being honest never knowing the truth. When

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Jenny said something to another charge nurse, she replied: I guess everybody has to earn their
stripes.
The next day Jenny decided to talk to the manager about this incident. She ended up
crying in her office. The manager expressed that he knew that Leah could be hard on new
people and that her bark was worse than her bite. He continued to mention that Leah was a
crackerjack nurse with a heart of gold and for Jenny to give it some more time. The manager
told her that she was showing some great potential, but should try not to be so sensitive. Jenny
left the office feeling distraught and hopeless. Over the next few weeks, Jenny dreaded going to
work and started to feel very depressed and lonely. She had no mentor, and no one even offered
to help her adjust. A nurse who had started two weeks after she did ended up quitting within one
month. Jenny is not happy in her job and has decided to quit.
Root Cause Analysis
It would be easy to put the blame on a single person for this tragedy, but the reality is that
it was multiple factors that permitted this sentinel event to occur. In health care it is of much
importance to understand that a medical related problem often has more than one cause
(Connelly, 2012). A root cause analysis is a tool used to identify the factors that were at fault
when this tragedy happened. In nursing, it is part of the job description to provide the best
possible care based on evidence based practice. Doing a root cause analysis helps in that regard
by reducing errors from happening in the future (Sherwin, 2011). Although a major goal of a
root cause analysis is to remove human error, it does not blame a single person; it actually
examines the entire system (Sherwin, 2011). In the tragic incident of Rachel Anne Gray people,
policies, technology, and environment contributed to her death.
People

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In this sentinel event, the people that could be looked at for having contributed to the
sentinel event are the two nurses and the doctor. Nurse Sharon was bullying and making Nurse
Jenny feel extremely uncomfortable. Sharon manipulated the situation so that Jenny would look
at fault of the situation by withholding patient lab results from the doctor while Jenny was away
at lunch. Attempting to make Jenny look bad to all the staff in the ED, cost the life of an
innocent patient with a bright future. Jenny is to blame due to her tolerance of the harassment.
If she would have stood up for herself as soon as she felt uncomfortable this might not have
happened. When disruptive behavior is allowed in the unit, nurse job satisfaction and production
is negatively affected (Lachman, 2014). The doctor was at fault due to the fact that he ignored
the first concern of Nurse Jenny. He lacked confidence in the nurses ability to assess a patient to
the extent of not even double checking if the patient looked okay. The nurse-doctor relationship
is looked at as a possible barrier to collaboration (Pullon, 2008).
Policies
The hospital has a policy in which the nurses have to take their lunch when it is
scheduled with no exceptions. If the hospital would have allowed Jenny to take her lunch after
receiving the patients lab values, then the patient would have had a better prognosis. Another
defective policy is that the lab values, normal or abnormal, are just imputed to the computer for
people the medical team to see, but the doctor is not alerted. If the lab was to notify the doctor
every time there is a severely abnormal lab value it would have increased the chance of survival
for this patient.
Technology
The hospital does not have mobile communication devices for the medical team to use
when they are away from the unit. While Jenny was out at lunch she could have requested a

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phone call from the lab for any abnormal lab values on the patient. Having that tool of
communication would have allowed her to make an immediate phone call to the doctor about the
patients abnormal lab values. Direct wireless cellular communication improves communication
times, communication accuracy, communication satisfaction, and minimizes interruption
(Ortega, Taksali, Smart, & Baumgaetner, 2009).
Environment
The environment has a huge impact on the efficiency and productivity of any medical
institution. The two big factors in this case were environmental incivility as well as the hospital
being understaffed. Jenny had been feeling the incivility since the day she began on this floor.
There was no help available when she felt attacked by the other nurses especially Sharon.
Incivility makes it extremely difficult to do the job with the highest of quality. Many people
even decide to leave the job they are at due to incivility in the work setting. There was a survey
conducted of 775 industrial employees and the results were that, due to incivility, 53% lost work
time because of worry about an uncivil incident, 46% contemplated changing jobs, 37% had a
decreased commitment to the organization, 28% lost time at work to avoid instigators of
incivility, 22% decreased their effort at work, 10% decreased their time at work, and 12%
changed jobs (Hutton & Gates, 2008). The other big issue is the understaffing of nurses and
doctors that is occurring on a daily basis at this hospital. If there were more employees available
for Jenny to befriend or at least have a professional relationship with, then she could have gone
to them when she had the concern with her patient. If there were more nurses on the floor they
would have more time to be able to check on coworkers patients while they are away from the
unit. The doctor involved in this tragic incident did not have much help in the ED, which limited
him in time to see patients. If the doctor had more time in his hands then he might have taken

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the time to reassess the patient when Jenny came to him with her concern. According to the
World Health Organization, there is a shortage of roughly 43 million health care workers
worldwide. The result of this being that time is a scarce resource in the hospital setting (Gilbert
& Yan, 2008).
Change/Action plan
Change is something that inevitably needs to happen in any organization regardless of
what the organization is for. Our society changes fast, and organizations that can keep up with
the change in society have an advantage and thrive. The ones who fail to do so tend to collapse
(Mindtools.com, 2014). An effective way to help change occur is by using the Lewins theory
for change, which was developed by Kurt Lewin in the 1950s. This theory has three different
steps that need to happen for change to be implemented. The three steps in the Lewins Theory
are the unfreezing, changing, and refreezing (Mindtools.com, 2014).
The targeted change that is trying to be attained through this process is the reduction of
lateral violence between nurses in the hospital setting. The stakeholders in this situation are the
nurses, doctors, patients, and hospital administrators. The nurses role is caring for the patient
directly, any mistake or unethical decision by them can cause harm toward the patient. If the
lateral violence among the nurses is changed, they would be able to work in a more productive
environment and allow them to provide a higher quality of care. The doctors role in the hospital
is to diagnose and medically treat patients. Their most important job is to attempt to keep
patients alive whenever possible. The doctor relies on the nurses daily to help with the care of
patients. If the nurses are not doing their job correctly, then it makes it difficult for the doctor to
work effectively. Patients, they are what keeps the hospital running as well as allow us to have a
job. They come to the hospital with the hope that when they are discharged everything is going

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to be better than when they were admitted. With the nurses doing their job at the best of their
ability, the patient would receive the highest quality of care and have better health outcomes.
The hospital administrators role is to maintain a successfully functioning hospital. They need to
make sure it holds a high reputation in the quality of care provided while the hospital is thriving
financially. The target population in this case is the nursing staff due to the fact that they are who
the patient spends the most time with while they are cared for in the hospital. When nurses are
being disruptive toward each other via lateral violence, it hinders their ability to provide the best
quality of care. This affects the patients directly and in this case it killed a patient, so if change is
successful in this population it would make hospital a safer place for patients. Currently, the
target population has a poor attitude and belief toward how nurses should be treating each other.
The aggressors have the mentality one must earn their stripes before any respect is shown. They
take advantage of the new nurses, as well as tormenting them whenever possible. The victims
are scared to stand up for themselves and tolerate much more than they need to from the abusive
co-workers. Both the aggressors and the victims are doing the wrong thing here.
It is essential that change occurs using the Lewins theory for change as soon possible for
the betterment of this organization. The first step of this theory is the Unfreezing step, which
is meant to show that the way things are being done can no longer continue (Mindtools.com,
2014). The first thing that would be done is have the nursing staff take an anonymous survey on
what they believe lateral violence is and if they have experienced it while working in this facility.
After the results there will be a small mandatory course that teaches the nursing staff what lateral
violence actually is. This will do two things. First off it will give a better understanding to what
the nurses knowledge is in the subject of lateral violence, and secondly it will not allow the
nurses to say they did not know they were being violent toward their fellow nurses. To assess if

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the environment in the hospital is adequate for working conditions and free of lateral violence
there will be nurses performing a tool called rounding for outcomes. Rounding for outcomes is
a strategy that is similar to physicians rounds, but it is focused on promoting a healthy work
environment (Longo, 2010). Another change that will occur is purchasing mobile
communication devices for the medical team. Mobile phones enable the medical team with ease
to obtain information that is required form the patient; they will be able to receive late changes
on patient status as well as call to get any information on the patients pathology results (Lack,
2000). Lastly the hospital policy about having to take lunch whenever the schedule states is
going to be changed. The change will be that the nurses will have the autonomy to make the
decision if the time scheduled is appropriate to take a lunch. This would prevent nurses from
having to go to lunch while a patient may be bleeding out like it happened in this scenario.
The second step in Lewins theory for change is called Change, and this is when the
targeted population starts to change the way they do things. This process is very slow and can be
denied by a large part of the targeted population. After all the actions for change have been made
there will be mandatory conference held at the hospital to inform all of the faculty of the changes
that are coming the facility. During this phase the management team will have to be available to
answer any burning questions the nursing staff might have. Management will need to remember
to answer every question as honest and clear as possible to avoid the start of any rumors. A way
to facilitate change would be by giving out awards to different units that are following the new
protocols that have been established. The awards will be ten dollar gift cards for each nurse in
the unit to Starbucks.
The third step of Lewins theory of change is called Refreezing. This does not occur until
the changes that are trying to be made become the norm among the targeted population. At this

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point the nursing staff are not treating one another in a disruptive manner through lateral
violence, all of the staff is effectively using the mobile phones that were provided, and nurses
will be able to express their reasons for not going to lunch on schedule when appropriate. While
this is happening there will be continuous affirmations to the nursing staff as well as being
available for concerns they might have.

References
Connelly, L. M. (2012). Root Cause Analysis. MEDSURG Nursing, 21(5), 316-313.

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Gilbert J. & Yan J. (2008). Letter to Author and Other Health Care Colleagues. World Health
Organization, Geneva.

Hutton, S., & Gates, D. (2008). Workplace incivility and productivity losses among direct care
staff. AAOHN Journal, 56(4), 168-175.
Lachman, V. D. (2014). Ethical Issues in the Disruptive Behaviors of Incivility, Bullying, and
Horizontal/Lateral Violence. MEDSURG Nursing, 23(1), 56-60.
Lack, J. A. (2000). Mobile communications in hospitals. Anaesthesia, 55(7), 695.
Longo, J. (2010). Combating disruptive behaviors: strategies to promote a healthy work
environment. Online Journal Of Issues In Nursing, 15(1), 3.
Mindtools.com. (2013). Lewins change management model: Understanding the three stages of
change. Retrieved October 19, 2014, from
http://www.mindtools.com/pages/article/newPPM_94.htm
Ortega, G. R., Taksali, S., Smart, R., & Baumgaertner, M. R. (2009). Direct cellular vs. indirect
pager communication during orthopaedic surgical procedures: A prospective study.
Technology & Health Care, 17(2), 149-157. doi:10.3233/THC-2009-0540
Pullon, S. S. (2008). Competence, respect and trust: Key features of successful interprofessional
nurse-doctor relationships. Journal Of Interprofessional Care, 22(2), 133-147.
doi:10.1080/13561820701795069
Sherwin, J. (2011). Contemporary Topics in Health Care: Root Cause Analysis. PT In Motion, 3(4), 2631.

The Joint Commission. (2014, October). Sentinel event data: Root causes by event type 2004-2Q
2014. Retrieved from

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http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_20042Q_2014.pdf

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