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Powers Sentinel Event
Sentinel events are unexpected occurrences involving death or serious physical or psychological injury or risk. Examples include suicide, wrong-site surgery, and infant abduction. A sentinel event differs from a medical error in its severity of outcome. Organizations are expected to report sentinel events, conduct a root cause analysis to identify causal factors, implement an action plan to reduce risks, and evaluate compliance through the survey process. The goal is to improve patient safety by learning from sentinel events.
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Powers Sentinel Event
- 2. 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
- 3. Difference Between MedicalError & Sentinel Event Medical 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or administer • Surgery on wrong patient, or body part correct drug • Incorrectly matched blood transfusion – Use of outdated drugs – 1,900 sentinel events reviewed by the Joint – Failure to observe correct time Commission since January 1995 – Lack awareness of adverse – Patient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
- 4. 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
- 5. 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
- 6. Sentinel Event isIdentified: • 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
- 7. 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
Editor's Notes
- #2 Slide 1:Hello, my name is Lori Powers, I want to thank you all for listening to my presentation. Today my presentation is on Sentinel Events. It is my hopes that after this presentation you will have a better understanding of what a sentinel even is, and what constitutes a sentinel event. With this knowledge we, in the healthcare field, will be better able to stop preventable events, and treat unforeseeable sentinel events when they happen. With that said let’s get started. NEXT SLIDE
- #3 The definition of Sentinel event is: CLICK And event that is unexpected and/or unanticipated event which has an outcome of death or serious physical or psychological injury, this includes the risk of a sentinel event.CLICK When a sentinel event is discoveredan investigation started. The Joint Commission analyses a disease-specific care programs’ actions in answer to sentinel events in its evaluation process, as appropriate.CLICK ● Serious injury specifically includes loss of limb or function. This includes any process deviation for which a reappearance would carry a substantial chance of a severe adverse effect. CLICK ● these types of events are called “sentinel,” due to the fact that they need instant analysis and reaction. CLICK ● Sentinel events are not the same as medical errors; Sentinel events do not always occur because of a medical error, and not all medical errors will cause in a sentinel event CLICK Some examples of sentinel events are; CLICK The patient is placed on a 24/7 suicide watch, but they commit suicide anyway. CLICKA full-term infant suddenly dies CLICK A baby is discharged to the wrong family CLICK A transfusion is performed on a patient that the blood was not matched correctly CLICK Surgery on the wrong body part, and surgery on the wrong patient NEXT PAGE
- #4 44,000 to 98,000 patients die each year from medical errors.So what is a medical error? The incorrect administration of drugs, unreadable drug order, incorrect combination or formulation of drugs for a given condition, unknown allergies to drugs, drugs not given at the right time.CLICK The most common medical errors include: read from slide. CLICK Sentinel Event:A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. CLICK examples of sentinel events; CLICK Read from slide then CLICK Over 1,900 sentinel events are reviewed by Joint Commission since Jan. 1995. According to the Joint Commissions:CLICK “Patient suicide accounted for 16.5% of the errors CLICK Operative/post-operative complication – 12.3% CLICK Wrong-site surgery – 11.7 CLICK Medication error – 11.5” NEXT PAGE
- #5 There are 4 goals in the Joint Commission sentinel event policy; I took these directly from the Joint Commission website, some words were changed but overall I let these as is: CLICK1. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events CLICK2. To focus the attention of a disease-specific care program CLICK3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention CLICK4. To maintain the confidence of the public and certified programs in the certification process. NEXT PAGE
- #6 Reporting expectations: CLICKCertified facilities should classify and respond properly to all sentinel events happening in their facility or any events related with the services that the facility offers. Responses to Sentinel events include: CLICKRoot Cause Analysis CLICKRoot cause analysis is the process for finding the basic or causal aspects that triggers deviation in performance, counting the incidence or potential occurrence of a sentinel event. A root cause analysis centers largely on systems and procedures, not on singular performance. CLICKAction Plan CLICKThe results of the root cause analysis is an action plan that classifies the tactics that the facility plans to implement in order to lessen the risk of like events happening again. CLICKSurvey Process CLICKWhen performing an accreditation survey, the Joint Commission look at the facilities compliance with the relevant standards and to score those standards on performance all through the facility over a period of. NEXT PAGE
- #7 If when conducting the normal survey activities, a sentinel event is identified the surveyor follows these steps: CLICK Inform the CEO that the event has been identified CLICKInform the CEO the event will be reported to the Joint Commission for further review and follow up CLICKReview the organization’s process for responding to a sentinel event CLICKInterview the organization’s leaders and staff about their expectations and CLICK responsibilities for identifying, reporting, and responding to sentinel events CLICKAsk for an example of a root cause analysis that has been conducted in the past year to assess the adequacy of the organization’s process for responding to a sentinel event. CLICKIn selecting an example, the organization may choose a “closed case” or a “near miss”‡ to demonstrate its process for responding to a sentinel event. CLICK FOR NEXT PAGE
- #8 A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. examples of sentinel events; A patient that is under 24/7 suicide watch manages to commits suicide. An full-term infant dies suddenly A family takes home the wrong baby Rape A transfusion is done with mismatched blood Surgery is performed on the wrong patient Surgery on the wrong body part. Goals of sentinel event policy To improving patient care, treatment, and services and preventing sentinel eventsTo focus the attention of a disease-specific care program changing the disease-specific care program’s systems, culture, and processes To increase the general knowledge about sentinel events, their contributing factors, and strategies To maintain the confidence of the public and certified programs Reporting expectations: classify and respond properly to all sentinel events Appropriate responses root cause analysis;Survey ProcessMedical Error:Medical error: medication is not correctly dispensed, ordered, or administered, incorrect drug is prescribed. The incorrect administration of drugs, unreadable drug order, incorrect combination or formulation of drugs for a given condition, unknown allergies to drugs, drugs not given at the right time. The most common medical errors include: Thank you for taking the time to listen to my presentation. Have a wonderful day.