SDSDS

1. TJC AND SENTINAL EVENTS

2. INTRODUCTION
 Professional accountability requires professionals to monitor performance as it
applies to patient outcomes. The identification of an undesired outcome may be a
result of direct or indirect action s

3. Definition
SENTINAL EVENT – an event that involves a risk for
or the occurrence of death or serious physical or
psychological injury, specifically includes loss of limb
or function
This is called sentinel because the seriousness of the
event requires immediate investigation and response

4. Root cause analysis
TJC has published guidelines for root
cause analysis
A fill in the blank questionnaire
It is done within 45 days of the event

5. Institutional reporting events
The patient safety and quality improvement act -
2005 encourages a culture of patient safety in
health care settings
States have adopted the national quality forums ,
list of 29 events
Surgical adverse events were the highest reported
of all categories in 2006

6. Reportable events Non reportable events
 Medication error that do
not cause death
 Event that does not affect
the recipient of care
 Death / injury after LAMA
 UNSUCCESSFUL suicide
attemts
 Minor hemolysis
 Suicide during treatment or within 72 hours of discharge
 Unanticipated death during the care of an infant
 Abduction while receiving care
 Discharge of an infant to the wrong family
 Hemolytic transfusion reaction
 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, Criminal event
 Falls
 Delay in treatment, Medication error

8. Never events and Reimbursement for
hospitals
 Air embolism
 Blood incompatibility
 CAUTI
 DVT or pul. Emboli after TKR/THR
 Falls or trauma during care
 Retained objects from surgery
 Pressure sore
 Surgical site infection retained object from surgery