This article outlines a sentinel event from Colorado that resulted in the death of a newborn. This 1996 case resulted in three nurses being indicted on charges of negligent homicide. The author of this article used information prepared for the trial to identify over 50 different failures in the system that allowed this error to develop, remain undetected and ultimately, reach the infant. As one of the article's most poignant points, the author states, "Had even one not occurred, the chain of mistakes would have been broken and the infant would not have been harmed."(p48).

In the article Smetzer (1998) identifies 14 system failures which include (a)  incomplete clinical information, (b) a language barrier (c) inconsistent procedure for communicating prenatal care (d) staff inexperience and poor documentation, (e) nonstandard method of writing the drug order (f) insufficient drug information (g) lack of a unit dose system, (h) insufficient information on infant injections (i) inconsistent independent double check system (j) lack of staff education before dispensing non-formulary drugs (k) insufficient drug information and inadequate drug references (l) unclear definition of non-physician prescriptive authority (m) unclear manufacturer label, and (n) conflicting information on IV use of milky white substances

For this learning assignment you must choose TWO system failures from Smetzer's list of 14 and complete the following assignment f or each system failure that you choose:

1. Write a paragraph explaining how the system failure contributed to the sentinel event of the article. What kind of precautions would be needed to avoid a repetition of this particular system failure? From which discipline might this precaution emerge (e.g. nursing, pharmacy, medicine, nursing administration, hospital administration).

2.  Locate an evidence based journal article that demonstrates either research being done in this area, or new recommendations to address this particular system failure. If you cannot find any evidence based practice, or research in this area, see if you can find a national initiative (e.g. 2010 National Patient Safety Goals, initiative from 5 Million Lives Campaign, initiative from The Leapfrog Group, IOM recommendation) that addresses this system failure.