Date of Award


Document Type


Degree Name

Doctor of Nursing Practice (DNP)

School Name

Donna and Allan Lansing School of Nursing and Health Sciences



Major Advisor

Sherill Nones Cronin, PhD, RN, RN-BC

Second Advisor

Nancy L York, PhD, RN, CNE

Third Advisor

Michelle Pendleton, DNP, RN


The purpose of this performance improvement project was to implement a standard sentinel event management model in an acute care hospital that is part of a healthcare system based on best practices and principles of high reliability organizations. The project used define, measure, analyze, improve and control (DMAIC) methodology and Lewin’s Theory of Planned Change. High rates of medical harm and preventable deaths have been demonstrated around the world. It is estimated that one in four American families will be affected by preventable harm in healthcare involving further medical care, disability or even death. Despite international awareness and substantial efforts for improvement, little to no progress has been made in preventing harm to patients. The response to adverse events in healthcare is the opportunity to learn what happened, why it happened and what may prevent a future occurrence. Adverse event management policies are heavily influenced by regulatory standards and litigation environments which may hinder prevention of future events. Efforts have been made to compare the successful safety records of high reliability organizations in healthcare to demonstrate long term organizational change. A clinical gap was identified between the current adverse event management policies and procedures of an acute care hospital and the best practice strategies from a literature review. Sentinel events are defined by The Joint Commission, and are a subcategory of the most severe adverse events in healthcare.

Included in

Nursing Commons