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What Is A Sentinel Event In Healthcare?

What Is A Sentinel Event In Healthcare
What is a sentinel event? – ‘Sentinel event’ refers to a subset of serious clinical incidents that have caused or could have caused serious harm or death of a patient. It refers to preventable occurrences involving physical or psychological injury, or risk thereof. Sentinel events are 10 specific types of clinical incidents:

  1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death.
  2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death.
  3. Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death.
  4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death.
  5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death.
  6. Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward.
  7. Medication error resulting in serious harm or death.
  8. Use of physical or mechanical restraint resulting in serious harm or death.
  9. Discharge or release of an infant or child to an unauthorised person.
  10. Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death.

Further description of the 10 sentinel event categories can be found in the Clinical Incident Management Guideline (PDF 2MB), In WA, sentinel events are categorised as Severity Assessment Code 1 (SAC 1) clinical incidents. The reporting of SAC 1 clinical incidents is mandatory for:

  • public hospitals
  • all private licensed health care facilities
  • nongovernment organisations (in accordance with their license or contract with WA Health).

Which is an example of a sentinel event?

Introduction – The Joint Commission defines a sentinel event as an unexpected occurrence involving death, serious physical or psychological injury. The event can result in death, permanent harm, or severe, temporary harm. The term sentinel refers to a system issue that may result in similar events in the future.

  1. The National Quality Forum defined the term serious reportable events as “preventable, serious, and unambiguous adverse events that should never occur.” These events are also termed as never events.
  2. Previously, sentinel events included events that occurred only to patients.
  3. In 2013, the concept was expanded to include “harm events” to the staff, visitors, and vendors on the organization’s premises.

Serious reportable events can be classified into the following categories:

  1. Surgical
  2. Device/product
  3. Care management
  4. Environmental
  5. Patient protection
  6. Radiologic event
  7. Criminal events

Hospitals vary in their definitions, investigations, and reporting of sentinel events. Examples of sentinel events from the Joint Commission include the following:

  • Suicide during treatment or within 72 hours of discharge
  • Unanticipated death during care of an infant
  • Abduction while receiving care
  • Discharge of an infant to the wrong family
  • Hemolytic transfusion reaction due to blood transfusion with major blood group incompatibilities
  • Surgery on the wrong individual or wrong body part
  • Retained foreign body after surgery
  • Severe neonatal jaundice (bilirubin >30 mg/dl)
  • Prolonged fluoroscopy with very high or inappropriate dose or to the wrong site
  • Fire during direct patient care caused by hospital equipment
  • Intrapartum maternal death
  • Unanticipated severe maternal morbidity resulting in permanent or severe temporary harm
  • Rape
  • Falls
  • Delay in treatment
  • Medication error
  • Criminal event

What is the difference between an adverse event and a sentinel event?

An Adverse Event is a serious, undesirable and usually unanticipated patient safety event that resulted in harm to the patient but does not rise to the level of being a Sentinel Event.

What process must be followed if a sentinel event occurs?

A hospital that reports a sentinel event must submit the comprehensive systematic analysis, including the resulting corrective action plan with measurement that describes the hospital’s risk reduction strategies as well as how the effectiveness of those strategies will be evaluated.

What are sentinel events in anesthesia?

Conclusion – Surgical safety checklists are widely used in otolaryngology and are generally acknowledged as the most effective intervention to reduce patient safety events; nonetheless, intraoperative sentinel events do continue to occur. Understanding the scope, causes, and response to these events may help to prioritize resources to guide quality improvement initiatives in surgical safety practices.

Keywords: sentinel events, checklist, otolaryngology, adverse events, patient safety events, operating room safety, operating room fire, wrong-site surgery, wrong-patient surgery, retained foreign body, medical error, patient safety, quality improvement The Joint Commission defines sentinel events as unexpected occurrences involving death or serious physical or psychological injury or the risk thereof.1 Such events are called “sentinel” because they signal the need for immediate investigation and response.

Although The Joint Commission allows hospitals to define their own list of additional sentinel events, mandatory reportable surgical events include surgery on the wrong patient, surgery on the wrong site, performing the wrong procedure, operating room fire, and unintended retention of a foreign object.

Sentinel events overlap with the National Quality Forum (NQF) list of serious reportable errors (termed colloquially as “never events”).2 The surgical checklist was adapted from the aviation industry to eliminate catastrophic accidents and is currently used in approximately 75% of operating rooms around the world.3 Checklists encompass many commonly labeled facets including preoperative huddles, in-room boarding process, preincisional time-outs, postoperative debriefs, and transfers to the next level of care.

Checklists serve to increase communication, standardize review of pre- and postsurgical concerns, and prevent sentinel events. Although surgical checklists are now widely used, adherence to optimal use is variable. Furthermore, much of the evidence supporting checklists has centered around general surgery, 4, 5 while the evidence within otolaryngology has been more limited.

We set out to understand sentinel events that occur in the modern operating room since the World Health Organization (WHO) published the surgical safety checklist as part of their Safe Surgery Saves Lives campaign in 2009, sparking widespread adoption. We surveyed members of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) on the use of surgical safety checklists, intraoperative sentinel events, and responses to such events.

This survey investigated wrong-site, wrong-patient, and wrong-surgery incidents; all types of airway fires; inadvertent administration of wrong medication; and retained surgical items.

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What is not a sentinel event?

An Adverse Event is a serious, undesirable and usually unanticipated patient safety event that resulted in harm to the patient but does not rise to the level of being sentinel. A No Harm event is a patient safety event that reaches the patient but does not cause harm.

Are all errors considered sentinel events?

Investigation and response. occur because of an error, and not all errors result in sentinel events.

Why is it called a sentinel event?

A sentinel event is ‘any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient’s illness’.

How do you avoid a sentinel event?

Reduce Alarm Fatigue – Providers across the care team continuum will almost certainly face alert & alarm fatigue at some point in their careers. Care team members face notification overload during every shift due to excessive alerts, false alarms, and multiple patient monitoring devices competing for their attention. What Is A Sentinel Event In Healthcare A communication system that can prioritize and manage alerts and notifications accurately addresses alarm fatigue by distinguishing notifications based on event and call type. Solutions that adjust notification sounds based on alert type help the end user understand the nature of the patient event before they even look at their phone or computer.

  • A sentinel event may be altogether avoidable if alarms are properly managed and escalated to the right person with the appropriate level of need.
  • Furthermore, the severity of a sentinel event can be reduced when providers are able to respond to the correct alarm promptly.
  • This is why a clinical communication system that automatically escalates alerts based on severity and notification type can save time, money, and—most importantly—lives.

It can even reduce the chance of the event occurring in the first place.

What is the most common root cause of sentinel events?

What are Examples of Sentinel Events? – The events are named “sentinel” because they signal the need for immediate investigation and response. As of Jan.1, 2022, The Joint Commission’s Office of Quality and Patient Safety (OQPS) revised its definition of a sentinel event and clarified some of the event-specific examples in the Sentinel Event Policy.

Sentinel event: A patient safety event (not primarily related to the natural course of the illness or underlying condition) that reaches a and results in death, severe harm (regardless of the duration of harm), or permanent harm (regardless of the severity of harm).

Severe harm: An event or condition that reaches the individual, resulting in life-threatening bodily injury (including pain or disfigurement) that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring or a surgery, invasive procedure, or treatment to resolve the condition.

Permanent harm: An event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline.

From a facility’s perspective, an example of a sentinel event could be a fall event or the failure of some equipment that is part of the regular building function. This could include the failure of room outlets to provide oxygen or failure of inlets to provide sufficient vacuum to a patient.

  1. According to the Joint Commission, the most common cause of sentinel events in healthcare includes unintended retention of a foreign object, fall-related events, and performing procedures on the wrong patient.
  2. Others include delay in treatment, medication error, and fire-related events.
  3. Falls resulting in injury are a prevalent safety problem.

The Joint Commission states, “A fall may be described as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). The fall may be witnessed, reported by a patient, an observer, or identified when the patient is found on the floor or ground.

What is the most common source of medical errors?

Communication Problems – Communication breakdowns are the most common causes of medical errors. Whether verbal or written, these issues can arise in a medical practice or a healthcare system and can occur between a physician, nurse, healthcare team member, or patient. Poor communication often results in medical errors,

What are sentinel events risk management?

Introduction – Risk management in healthcare is a complex set of clinical and administrative systems, processes, procedures, and reporting structures designed to detect, monitor, assess, mitigate, and prevent risks to patients. Currently, the numerous risk management practices and processes that occur in healthcare organizations are a response to The Institute of Medicine’s (“IOM”) report entitled “To Err is Human: Building a Safer Health System.” In the report, the IOM noted that approximately 98,000 people die in any given year from medical errors while in the hospital.

  • Provision for the certification and recertification of Patient Safety Organizations (“PSO’s”)
  • Collection and dissemination of information related to patient safety
  • Establishment of a patient safety database
  • Facilitation of the development of consensus among healthcare providers, patients, and other interested parties concerning patient safety and recommendations to improve patient safety
  • Provision of technical assistance to states that have (or are developing) medical-error reporting systems
  • Provision of assistance to the states in developing standardized methods for data collection and data collection from state reporting systems for inclusion in the patient safety database.

The fundamental goal of this act was to increase the nation’s overall patient safety by encouraging confidential and voluntary reporting of adverse events that affected patients. Policymakers theorized that the systematic collection of medical-error data could achieve improved patient safety.

  • The awareness of such error-data by health care providers and administrators would lead to the prevention of errors and the global reduction of their recurrence.
  • Relevant Definitions Sentinel Event: Defined by the Joint Commission as “a patient safety event that results in death, permanent harm, or severe, temporary harm” (The Joint Commission 2017).

These events are typically unrelated to the patient’s illness/underlying condition. It is important to note that the Joint Commission requires each accredited organization to establish its own definition for a sentinel event to prevent, review, and respond to these occurrences.

  1. Medical Error: The failure of a planned action to be completed as intended or using a wrong plan to achieve an aim.
  2. In the context of this article, medical errors may fall under the definition of sentinel events if the error is severe enough.
  3. Root Cause Analysis: The process for identifying the basic or causal factor(s) underlying variation in performance.
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Also established by the Joint Commission, this multi-step process is crucial to identify and fix systemic problems in patient safety and care. Risk Management: Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself (The Joint Commission 2017).

What is a critical incident in Anaesthesia?

INTRODUCTION – A critical incident is any preventable mishap associated with anesthesia administration which leads to or could have led to an undesirable patient outcome.1 Underlying causes are diverse, owing to unpredictable interplay amid patient factors, surgical procedure, and effects of anesthetic techniques and drugs.

A substantive portion of anesthetic risk may be related to a system or human error.2 The critical incident investigation was first used among military pilots aiming to improve their performance and safety.3 Cooper and colleagues applied the principle similarly in anesthesia.4 Studying critical incidents aids formulate strategies to prevent their recurrence.

This might improve anesthesia care and patient safety.5, 6 Not only developed countries but developing countries have adopted a system to monitor and report anesthesia-related incidents.7 – 11 However, no such initiatives are evident in our country.

What is considered an anesthesia event?

1.1 A surgical or anesthesia event involves surgery or other invasive procedure (e.g., colonoscopy) or the administration of anesthesia.

Is a pressure ulcer a sentinel event?

1 In addition, the development of Stage 3 and 4 pressure ulcers (see the section below for definitions) is currently considered by The Joint Commission as a patient safety event that could be a sentinel event. Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill.

What to do after a sentinel event?

Responding to a sentinel event Each year, medical errors result in 44,000 to 98,000 deaths in the United States. This is not a news bulletin; these statistics were revealed nearly a decade ago by the Institute of Medicine in its seminal report To Err is Human: Building a Safer Health System.

Since then, studies show that medical errors are the eighth leading cause of death in this country, killing up to 195,000 Americans every year. Despite the hard work ongoing nationwide to analyze and reform healthcare systems and thus improve safety, severe errors or sentinel events still occur—and they can happen in any facility at any time.

No organization or individual is immune. Sentinel events aren’t confined to substandard organizations. Many involve highly respected healthcare systems and practitioners. This article defines a sentinel event, explains why sentinel events may occur, and describes ways to handle them.

Defining a sentinel event Sentinel events are so named because they indicate the need for immediate investigation and response. The Joint Commission defines a sentinel event as: “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes 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 Commission points out that the term sentinel event isn’t synonymous with medical error. Not all sentinel events stem from an error, and not all errors lead to sentinel events.

Accredited healthcare organizations are required to define a sentinel event in a way consistent with the Commission’s definition and to set a policy for identifying, reporting, and managing such an event. (See Categorizing sentinel events in the downloadable pdf available at the bottom of this page.) Common sentinel events From January 1995 through September 2007, the Joint Commission reviewed 4,693 sentinel events.

It found that the top three sentinel events were:

wrong-site surgery (13.1%) suicide (12.2%) operative and postoperative complications (11.9%).

The Joint Commission’s universal protocol is designed to prevent wrong-site, wrong-procedure, or wrong-patient surgery. Nonetheless, for each hospital accredited by the Commission since 2004, wrong-site surgery was the leading sentinel event reported.

Is there a problem with our policies or procedures? Does our system have adequate built-in redundancies and safeguards for practitioners to effectively double-check the correct site preoperatively? What orientation and training processes are related to the universal protocol? Are all the right people participating? Are we performing periodic quality checks to determine whether the universal protocol is acceptable and being followed?

Why do sentinel events occur? Most sentinel events result from systemic problems rather than the mistake or failure of a single individual. Inadequate communication among healthcare providers is the number-one root cause of sentinel events. In 2006, the second leading root cause was incorrect assessment of a patient’s condition; the third leading cause was inadequate leadership, orientation, or training.

  1. Causes that may contribute to sentinel events include greater patient acuity and multiple comorbidities, greater dependence on medical technology, reduced lengths of stay, and shortages of nurses and other healthcare workers (which may decrease caregiver continuity).
  2. Also, after a hospital stay, the patient’s care may need to be coordinated with other departments, such as rehabilitation, long-term care, or home healthcare services; these multiple “hand-offs” of communication about the patient’s plans of care within a compressed period may set the stage for a sentinel event.

Handling a sentinel event A sentinel event can be seen as a set of concentric circles, with the specific patient situation in the innermost circle and the entire healthcare system in the outermost circle. When an untoward outcome or a question of inappropriate care arises, healthcare professionals first must attend to the innermost circle—the patient’s safety and well-being.

  • If the event involves medical equipment, that item must immediately be taken out of service, bagged, and labeled for investigation.
  • Next, the event must be communicated up the chain of leadership, and an occurrence report (or other report) must be submitted as required by the facility.
  • Each healthcare organization has a policy regarding disclosure of adverse events to patients and families.
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If you don’t know your organization’s specific policy, refer to the policy manual or risk management department. Root-cause analysis and action plan The Joint Commission requires that organizations conduct a root-cause analysis to identify contributing factors within 45 days of a sentinel event or becoming aware of the event.

  1. This analysis focuses on systems and processes, not individual performance.
  2. All persons involved with the event in any way should participate in the analysis, as each may have important insights and observations.
  3. The sooner root-cause analysis takes place, the better—while the circumstances are fresh in participants’ minds.

(See Helping the helpers in the downloadable pdf available at the bottom of this page.) Root-cause analysis digs progressively deeper into the event, repeatedly asking why the event occurred and exploring in depth the circumstances that led to it, to determine where improvements can be made.

  • The analysis may identify common and special causes, leading to implementation of an action plan for strategies to reduce the risk of similar events.
  • Organizational leaders and risk managers should determine whether the event must be reported to the Joint Commission or other entity, such as a state healthcare regulatory agency.

The organization must submit its root-cause analysis and action plan to the Commission within 45 days of the event. The action plan should describe the organization’s risk-reduction approach, set a definitive timeline, assign responsibility for implementation and oversight, specify pilot testing as appropriate, and delineate strategies for measuring the plan’s effectiveness.

In addition to addressing the innermost concentric circle of the sentinel event, the plan should spiral out to the larger circles enclosing the entire organization—even, in some cases, to other healthcare systems. If the sentinel event must be reported to the Commission or other entity, representatives of these groups might visit the facility to check on compliance and adherence to the action plan.

Ordinarily, the Commission doesn’t conduct an on-site review unless it finds a potential ongoing immediate threat to patient health or safety or potentially significant noncompliance with its standards. Nonetheless, healthcare organizations should always be ready for regulatory-body inspection and review.

Reporting sentinel events and their root-cause analyses and action plans to the Commission broadens the Commission’s sentinel event database. This, in turn, enhances knowledge about sentinel events and helps reduce the risk of these events happening in other facilities. The Joint Commission publishes sentinel event alerts that identify specific sentinel events, along with their common underlying causes and steps to prevent them.

Organizational leaders should share these alerts with staff to promote education and incident prevention. Toward a culture of safety Despite everyone’s best intentions, not all sentinel events can be prevented. But sustaining a culture of safety and promoting continual performance improvement can help prevent adverse outcomes.

Facility leaders should ensure that staff members feel empowered to share their ideas for error prevention, report errors and near-misses, and question any practitioner or stop any process that imperils patient safety. Barbara C. Sorbello is the Administrative Director of Acute Care Services at Bon Secours St.

Francis Medical Center in Midlothian, Virginia. Selected references Buerhaus P. Lucian Leape on patient safety in US hospitals. J Nurs Scholarsh.2004;36(4):366-370. Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

What is the most common patient safety incident?

What is the most commonly reported incident? – Medication-related incidents are the most commonly reported incidents in healthcare. This includes administering the wrong dose, giving medication to the wrong patient, or omitting the dose. For example, a nurse may scan a medication barcode, get distracted, and then grab the wrong bottle and administer the wrong medication.

Is infection a sentinel event?

‘Sentinel event’ means an unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof, including, without limitation, any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

What is an example of an adverse event?

Other Serious (Important Medical Events) – Report when the event does not fit the other outcomes, but the event may jeopardize the patient and may require medical or surgical intervention (treatment) to prevent one of the other outcomes. Examples include allergic brochospasm (a serious problem with breathing) requiring treatment in an emergency room, serious blood dyscrasias (blood disorders) or seizures/convulsions that do not result in hospitalization.

What is always true regarding a sentinel event?

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Sentinel events requires an immediate investigation by the Joint Commission. The state of Florida, requires a Root Cause Analysis to be completed.

Which is an example of a sentinel event quizlet?

A patient commits suicide. Patient suicide is a sentinel event.

Which would be a sentinel event quizlet?

Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome.

Is a pressure ulcer a sentinel event?

1 In addition, the development of Stage 3 and 4 pressure ulcers (see the section below for definitions) is currently considered by The Joint Commission as a patient safety event that could be a sentinel event. Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill.

What is a radiation sentinel event?

Sentinel Event for Fluoroscopy or Radiotherapy The Joint Commission considers the following a sentinel event:

Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or, Any delivery of radiotherapy to the wrong body region or > 25% above the planned radiotherapy dose.

Most diagnostic fluoroscopy procedures are of short duration, and the skin doses received by patients are well below CRI threshold levels. However, fluoroscopically-guided interventional (FGI) procedures may require the prolonged use of fluoroscopy. Complex FGI procedures can result in PSD levels high enough to cause skin injury.

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