sentinel events

1. SENTINEL EVENTS
Vidya Prasad

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.

21. THANK YOU