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Powers Sentinel Event

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Powers Sentinel Event

  1. 1. Sentinel Event Unexpected/unanticipated outcome • Death • Serious physical/phsychological injury or risk • Examples: – Loss of limb or function – Patient on suicide watch commits suicide – Unexpected death of full-term infant – Infant abduction – Infant discharged to wrong family – Rape – Reaction to mismatched blood – Surgery on wrong patient/wrong body part
  2. 2. Difference Between Medical Error &Sentinel EventMedical Error: Sentinel Event:– 44,000 and 98,000 Americans die – Death each year – Physical/phsychological injury or risk • Loss of limb or function • Common Medical Errors • Suicide – Incorrect administration of • Rape medication • Infant death – Dosage or route of administration • Infant discharged to wrong parents – Failure to prescribe or administer • Surgery on wrong patient, or body part correct drug • Incorrectly matched blood transfusion – Use of outdated drugs – 1,900 sentinel events reviewed by the Joint – Failure to observe correct time Commission since January 1995 – Lack awareness of adverse – Patient suicide accounted for 16.5% of the errors effects. – Operative/post-operative complication – 12.3% – Hard to read handwritten orders – Different drugs – Wrong-site surgery – 11.7 – Drug allergies – Medication error – 11.5
  3. 3. Sentinel Event Policy• To have a positive impact in improving patient care, treatment, and services and preventing sentinel events• To focus the attention of a disease-specific care program that has experienced a sentinel event• understanding contributed factors to an event (such as underlying causes, latent conditions, and active failures in defense systems or organizational cultures)• disease-specific care program’s systems, culture, and processes to reduce the probability of such an event in the future• To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention• To maintain the confidence of the public and certified programs in the certification process
  4. 4. Expectations for Organizations• Reporting: – Root Cause Analysis • Process to identify basic or causal factors of sentinel events current or in future – Action Plan • Plan to identify strategies to implement reduced risk of sentinel events – Survey Process • Evaluate the facilities compliance with applicable standards • Score performance
  5. 5. Sentinel Event is Identified:• Surveyor reporting steps: – Inform the CEO • Sentinel event identified • Reported to Joint Commission for review and follow up – Review process for responding to sentinel event – Interview leaders – Get examples of root cause analysis » Examples can include closed cases or a near miss
  6. 6. In Summary• Sentinel Event: • Reporting: – Unexpected – Classify and respond to sentinel • Death event • Physical/phsychological injury or risk • Root cause analysis – Loss of limb or function • Action plan – Suicide • Implement improvements – Rape – Infant death • Medical Error – Infant discharged to wrong parents – Incorrect administration of medication – Surgery on wrong patient, or body • Dosage or route of administration part • Failure to prescribe or administer – Incorrectly matched blood transfusion correct drug • Use of outdated drugs• Policy: • Failure to observe correct time • Improving • Patient care • Lack awareness of adverse effects. – Hard to read handwritten orders • Treatment – Different drugs • Services – Drug allergies • Preventing sentinel events • Focus on disease specific care • Increase knowledge

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