1. Use a system approach to remedy a sentinel event instead of punitive action when a detox patient dies Marie Bettie Douyon

2.  Spradley’s model theory will be used to implement change. His theory has eight basics steps to follow  1-Recognize the symptoms: realizing the sentinel event took place, where is the flaw in the system, what can be done to make changes.

3.  2- Diagnose the problem: get to the root cause of the incident. What was done? what was not done to avoid it? Was the patient on too much medications?  Was the patient getting the medications within a safe distance from each other?  Was the patient cheeking the medications? Was mouth check being done?

4.  Was patient receptive to teaching?  If patient is not receptive, what can be done to reinforce receptivity? Provide printed information to patient about the medications and their risks.  Was patient argumentative and being unsafe on the unit with the medications received?  Other hospitals have shorter detox time frame, and use alternative medication more than detox medication.

5.  3-Analyze alternative solution: what can be done to avoid reoccurrence? Is the organization practicing safe detox protocol?  What can be done to make it safer for detox patients?  Do we need to raise the numbers on the detox protocol, therefore making less likely for detox patient to get detox medication.

6.  Do we need to use alternative medications for withdrawal symptoms?  We need to use safer detox protocol, therefore preventing any more sentinel event, decrease liability damage to the organization.

7.  4- Select change  Detox scale protocol will be raised higher, therefore making it safer for patient, patient will get the lowest dose possible on the scale  Alternative non-detox medications will be used in case of withdrawal symptoms (vistaril, seroquel, clonidine, & motrin).

8.  5- Plan the change: develop a policy, give time when policy will be in effect. Patient detoxing is to have a BP>= 90/70, P 60, & Pox 96%, anything less than that detox medication will be held.  Alternative medications to be used in case BP falls below parameters, or MD should be called for approval for any BP< 90/70.

9.  6- Implement change: in-service should be provided to staff prior to implementing new policy. Go over new detox scale protocol with staff.  Explain the rational for the change, certain drugs are no longer permitted for detox patients as far as methadone, soma, or narcotic pain medication. Alternative pain medication has to be used.

10.  7- Evaluate change: monitor outcome of new protocol after a time frame. Did it do what it was set out to do, which is to keep patient safe. Are patient detoxing safely?  Use data from other institutions detox protocol for comparisons.

11.  8- Stabilize the change: detox patient gets the lowest dose on the detox protocol, which makes it safer practice for staff & patients’ involved.  At times patient will become argumentative over dosage of medication. Reinforced teaching will be done with patient in those cases.

12. References Roussel, L. (2013). Management and leadership for nurse administrators (6 th.). Burlington, MA: Jones & Bartlett Learning.