Sentinel Events

sentinel events

1. SENTINEL EVENTS Vidya P rasad

2. INTRODUCTION A Sentinel Event is defined as :- Any unanticipated event in a healthcare setting resulting in  death  or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness by  The Joint Commission   An unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of healthcare services by NABH

3. Loss of function refers to sensory, motor, physiological, or psychological impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition.

4. A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following: Death Permanent harm Severe temporary harm and intervention required to sustain life 

5. Types of Sentinel Events The types of Surgical events are following : Surgical Events ( wrong body part/ patient/ procedure, retained instrument, death during the procedure, anesthesia related events) Device or Product events (contaminated drugs and device, unintended use, breakdown or failure) Patient protection events (infant discharge to wrong person , elopement, suicide, attempted suicide, self-harm, intentional injury, nosocomial infection, medical gas ) Environmental events ( burn, slip, trip, fall, electric shock, use of restrains and bed rails) Care management events (hemolytic reaction, maternal death, medication errors, delay in response) Criminal events (impersonation, abduction, sexual assault, physical assault on the grounds of healthcare facility)

6. Types of Sentinel Events Surgical events Surgery or other invasive procedure performed on the wrong body part Surgery or other invasive procedure performed on the wrong patient Wrong surgical or other invasive procedure performed on a patient Unintended retention of a foreign object in a patient after surgery or other procedure Intraoperative or immediately postoperative/ postprocedure death in an American Society of Anesthesiologists Class I patient

7. Types of Sentinel Events Product or device events Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the health care setting Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used for functions other than as intended Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a health care setting

8. Types of Sentinel Events Patient protection events Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person Patient death or serious disability associated with patient elopement (disappearance) Patient suicide, attempted suicide, or self-harm resulting in serious disability, while being cared for in a health care facility

9. Types of Sentinel Events Care management events Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) Patient death or serious injury associated with unsafe administration of blood products Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a health care setting Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy

10. Types of Sentinel Events Care management events Artificial insemination with the wrong donor sperm or wrong egg Patient death or serious injury associated with a fall while being cared for in a health care setting Any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care facility Patient death or serious disability resulting from the irretrievable loss of an irreplaceable biological specimen Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

11. Types of Sentinel Events Environmental events Patient or staff death or serious disability associated with an electric shock in the course of a patient care process in a health care setting Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or is contaminated by toxic substances Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a health care setting Patient death or serious injury associated with the use of restraints or bedrails while being cared for in a health care setting

12. Types of Sentinel Events Radiologic events Death or serious injury of a patient or staff associated with introduction of a metallic object into the MRI area

13. Types of Sentinel Events Criminal events Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed health care provider Abduction of a patient/resident of any age Sexual abuse/assault on a patient within or on the grounds of a health care setting Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a health care setting

14. 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. The second leading root cause was incorrect assessment of a patient’s condition. The third leading cause was inadequate leadership, orientation, or training.

15. 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. If you don’t know your organization’s specific policy, refer to the policy manual or risk management department.

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

17. …….CONT 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.

18. …..CONT 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.

19. …..CONT 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.

20. …..CONT 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.

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