Quick Answer: Why Do Sentinel Events Occur?

What is a sentinel event and why is it important to risk management?

The Sentinel Event Policy Careful investigation and analysis of Patient Safety Events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm..

When should a sentinel event be reported?

The initial review of a potential Sentinel Event must be initiated within the first three working days of notification of the event. A thorough and credible root cause analysis and action plan should be completed within 45 calendar days of the event or of becoming aware of the event.

What is the difference between a sentinel event and an adverse event?

Patient Safety Events – Sentinel events are one category of patient safety events. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. … An adverse event is a patient safety event that resulted in harm to a patient.

Which example qualifies as a sentinel event?

Sentinel events are unexpected events that result in a patient’s death or a serious physical or psychological injury. Examples of the most commonly occurring sentinel events include unintended retention of a foreign object, falls and performing procedures on the wrong patient.

How do I report a sentinel event?

Call the sentinel event hotline at (630) 792-3700, or visit The Joint Commission’s Web site, www.jointcommission.org.

How do you handle sentinel events?

5 Steps to Handling a Sentinel Event From The Joint CommissionSecure the situation — ensure the immediate safety and wellbeing of any directly involved patients and staff.Preserve and sequester anything that might be helpful in analysis process — this may include equipment, medication and more.More items…•Oct 21, 2013

When must a root cause analysis be completed for a sentinel event?

Preparation for RCA begins immediately after the event is declared sentinel. The Joint Commission allows 45 days for completion of the analysis and development of an action plan. Delays in beginning the process could result in unnecessary stress to meet the deadline.

What is a sentinel review?

Medical professionals use sentinel event reviews to examine unexpected patient deaths, medication errors, wrong-patient surgeries, “near misses” and similar incidents to account for their root causes. These reviews focus on reducing future risk, not on fixing blame for past mistakes.

What is the leading cause of sentinel events?

The most common sentinel events are wrong-site surgery, foreign body retention, and falls. [3] They are followed by suicide, delay in treatment, and medication errors. The risk of suicide is the highest immediately following hospitalization, during the inpatient stay, or immediately post-discharge.

What is a sentinel event in healthcare?

A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm.

Are sentinel events preventable?

Because SSEs require a deviation from generally accepted performance standards, they are considered preventable. Sentinel events do not necessarily require a deviation from best practice and, as such, they may not be preventable.

Is medication error a sentinel event?

JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order.

Is a close call or near miss a sentinel event?

A close call (or “near miss” or “good catch”) is a patient safety event that did not reach the patient. A hazardous (or “unsafe”) condition(s) is a circumstance (other than a patient’s own disease, process, or condition) that increases the probability of an adverse event.

What is considered a serious safety event?

A serious safety event (SSE) is a variation from expected practice followed by death, severe permanent harm, moderate permanent harm, or significant temporary harm.

What is the root cause for 82% of sentinel events?

Sentinel Events 2004-2015 body and wrong–patient, wrong-site, wrong-procedure (see Figure 1). The majority of SEs had multiple root causes (see Figure 2) with human factors as the most frequently reported root cause. Standards for Hospitals, 6th Edition.

What is the number one sentinel event reported to the Joint Commission?

The Most Common Sentinel Events According to The Joint Commission, the most commonly occurring sentinel events include unintended retention of a foreign object, falls, and performing procedures on the wrong patient.

Is a near miss a sentinel event?

A close call (or “near miss” or “good catch”) is a patient safety event that did not reach the patient. … The hospital determines how it will respond to patient safety events that do not meet The Joint Commission’s definition of sentinel event.

When discussing an adverse event with a patient a best practice is to?

When discussing an adverse event with a patient, explain what happened and why; do not, however, accept or assign blame. When dealing with a conflict between you (the provider) and the patient or his or her family, it is best to continue to work alone toward building a better relationship.

Is infant abduction a common sentinel event?

Infant abduction is a sentinel event, as defined by The Joint Commission’s Sentinel Event policy, which requires organizations to conduct an immediate comprehensive systematic analysis and respond to the event.