Sentinal Events
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We had a dreaded "sentinal event" in our ED. Major hospital in a poor community, multiple boarded pts "holding" in the ED, administration that's oblivious, the usual. Anyway, an older woman presents to triage with vague, but potentially serious symptoms, 4 hours later codes in the waiting room, is rushed back and eventually dies. Our is ED is constantly saturated. Our pts move out slowly and check in faster than you can obtain vitals on them, let alone triage them properly. In this instance, the pts vitals were stable, she was triaged properly, but she had a massive bleed. How can every death be prevented and how can the triage nurse be held responsible? There just is no room.....