Sentinel Events

Sentinel Events: Not Reviewable

Any "near miss." Full or expected return of limb or bodily function to the same level as prior to the adverse event by discharge or within two weeks of the initial loss of said function. Any sentinel event that has not affected an individual. Medication errors that do not result in death or major permanent loss of function. Suicide other than in an around-the-clock care setting or following development from such a setting. A death or loss of function following a discharge "against medical advice (AMA)." Unsuccessful suicide attempts. Minor degrees of hemolysis not caused by a major blood group incompatibility and with no clinical sequelae.

Top Root Causes

Communication Orientation/training Patient assessment Staffing Availability of info Competency/credentialing Procedural compliance Environmental safety Leadership Continuum of care Care planning Organization culture

Sentinel Events: Most Reported 2018

Fall — 111 reported Unintended retention of a foreign body — 111 Wrong-site surgery — 94 Unassigned — 68 Unanticipated events such as asphyxiation, burn, choking on food, drowning or being found unresponsive — 59 Suicide — 50 Delay in treatment — 43 Product or device event —29 Criminal event — 28 Medication error — 24

Reducing Patient Harm

Harm can come from many sources. Nurses used to take the "Nightingale Pledge". IOM: guidelines recommend evidence based and individualized care based on pt needs and values. Joint Commission: emphasis on Root Cause Analysis through process of identifying and analyzing "sentinel events".

Sentinel Events

Joint Commission reviews activities in response to sentinel events in its accreditation process, including all triennial and random unannounced surveys. A sentinel event is 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. Such events are called "sentinel" because they signal the need for immediate investigation and response.

Florence Nightingale

Notes on hospitals 1859. Origins of nurses do no harm come from this. "It may seem a strange principle to enunciate as a very first requirement in a Hospital, that it should do the sick no harm"

Root Cause Analysis

Process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. Process of evaluating data, process audit. Most errors or untoward outcomes result from deficiencies in the process.

Sentinel Events: Joint Commission

The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. The organization requires hospitals to conduct a root-cause analysis after a sentinel event occurs.

Sentinel Events: Reporting

The numbers may seem somewhat small but sentinel events should not occur. Less than an estimated 2% of all sentinel events are reported to The Joint Commission. Organizations are not required to report but are encouraged to report.

Sentinel Events: Policy Goals

To have a positive impact in improving patient care. To focus the attention of an organization which has experienced a sentinel event on understanding the causes that underlie that event, and on making changes in the organization's systems and processes to reduce the probability of such an event in the future. To increase the general knowledge about sentinel events, their causes, and strategies for prevention. To maintain the confidence of the public in the accreditation process.