Sentinel Events Flashcards

Florence Nightingale

• Published "Notes on Hospitals" in 1859, establishing foundational nursing principles.
• Introduced the concept of "do no harm," emphasizing patient safety in healthcare settings.

Reducing Patient Harm

• Harm in healthcare arises from various sources; nurses historically adhered to the "Nightingale Pledge."
• The Institute of Medicine (IOM) advocates for evidence-based, individualized care tailored to patient needs and preferences.
• The Joint Commission focuses on Root Cause Analysis to evaluate sentinel events and implement corrective measures.

Sentinel Events

• Defined by The Joint Commission as unexpected occurrences that result in death or serious injury, including psychological harm.
• Serious injuries encompass loss of limb or major functions, with implications for potential risks needing immediate investigation.

Sentinel Events: Policy Goals

• Aim to enhance patient care and understand the underlying causes of sentinel events.
• Encourage changes in systems and processes to minimize future occurrences.
• Increase awareness and knowledge regarding sentinel events and their prevention to maintain public trust in the accreditation system.

Sentinel Events: Most Reported 2018

• Most frequently reported events include:
  • Falls: 111 occurrences
  • Unintended retention of foreign bodies: 111 occurrences
  • Wrong-site surgeries: 94 occurrences
  • Unassigned incidents: 68 occurrences
  • Unanticipated events (e.g., asphyxiation, burns): 59 occurrences
  • Suicide: 50 occurrences
  • Delay in treatment: 43 occurrences
  • Product/device events: 29 occurrences
  • Criminal events: 28 occurrences
  • Medication errors: 24 occurrences

Sentinel Events: Reporting

• Estimated that <2% of all sentinel events are reported to The Joint Commission.
• Reporting is encouraged but not mandatory for organizations.

Sentinel Events: Joint Commission

• A sentinel event is a patient safety incident that leads to death, permanent harm, severe temporary harm, or life-sustaining intervention.
• The Joint Commission mandates root-cause analysis post-sentinel event to identify contributing factors.

Sentinel Events: Not Reviewable

• Exclusions from review include:
  • Near misses and events with full recovery.
  • Medication errors without severe outcomes.
  • Suicides outside 24/7 care environments or following discharge against medical advice.
  • Minor harm occurrences lacking significant clinical implications.

Root Cause Analysis

• A methodology to pinpoint fundamental factors leading to performance variations and sentinel events.
• Emphasizes data evaluation and process audit to address underlying process deficiencies contributing to errors.

Top Root Causes

• Factors contributing to sentinel events include:
  • Communication breakdowns
  • Inadequate orientation/training
  • Insufficient patient assessment
  • Staffing issues
  • Lack of accessible information
  • Competency and credentialing concerns
  • Noncompliance with established procedures
  • Environmental safety hazards
  • Inadequate leadership
  • Gaps in the continuum of care
  • Deficient care planning
  • Weak organizational culture