Although rare, Sentinel events are always possible in healthcare settings. It can be scary to think about, but you and your loved ones should always be prepared in case it happens. This becomes even more important with age as visits to health centers may become more frequent.
While they can happen to anyone, the most common patients who experience sentinel events are infants and the elderly. This is due both to the nature of the facts and to theFrequency of visits to the doctor.for these age groups. While you can never guarantee that it won't happen to you or your loved one, it's important to understand what counts as a sentinel event and what your options are in order to take the right steps toward healing and hopefully protect future patients from having the same experience. .
What is a sentinel event?
A sentinel event is an event that results in severe temporary harm, permanent harm, or death to a patient.The harm may be physical or psychological and is not primarily related to the patient's underlying disease or condition. These events reveal vulnerabilities in the healthcare system and can range from negligent accidents to serious medical errors.
Although the term "sentinel event" generally refers to a situation that harms a patient, it could also be used to describe harm to staff or visitors within the health care facility. A sentinel event speaks to the safety of a health facility, so any situation that could be considered unsafe and preventable falls into this category and should be further investigated.
Joint Commission on Sentinel Events
The Joint Commission, a health care accrediting agency, is committed to ensuring quality care and patient safety, which is why they established aSentinel Event Policy. The Sentinel Event Policy defines a sentinel event and helps hospitals and other healthcare organizations detect failures and improve security in the future. While facilities are not required to report incidents, they are strongly encouraged to do so. Even if the event is not reported to the Joint Commission, organizations are still required to conduct their own root cause analysis.
To provide patients with the best possible care, healthcare organizationsshould have its own policy for sentinel events. This policy may be based on the Joint Commission's policy and definitions, although it should be relevant to the patient population of each facility. Individual sentinel event policies should also be consistent across the organization to clearly define when incidents should be escalated and reported.
By working with healthcare organizations to record and analyze dangerous or harmful events, overall patient safety can be greatly improved. This not only holds organizations accountable for preventable accidents and carelessness, but also helps organizations understand what practices need to be adjusted or re-evaluated to better protect patients in the future.
9 examples of sentinel events
Sentinel events can take many forms. Whether it's a negligent mistake or an actual accident, preparing for different events can help you keep an eye on situations and know exactly what to do if it ever happens.
falls
Although they were only included in the Joint Commission's definition of a sentinel event in January 2021, falls are currently the case.one of the most common sentinel eventsreviewed by the organization. The Joint Commission does not have an official definition of fall; however, one must be established within an organization. For the fall to be considered a sentinel event by the Joint Commission, the patient had to sustain a major injury, require additional treatment (eg, surgery, cast, or ongoing care), or die as a result of the fall.
delay in treatment
delay in treatmentit is one of the other more common Sentinel events reported to the Joint Commission. This event is defined as a patient who does not receive the ordered treatment within the indicated period. Delaying treatment could delay diagnosis or follow-up to prevent further harm or death.
Accidental retention of a foreign object
Unfortunately, the inadvertent retention of a foreign object is also a common Sentinel event reported to the Joint Commission.Accidental retention of a foreign objectis when a foreign body remains in a patient's body during an invasive procedure. At the very least, this may cause additional procedures to dispose of the debris. In the most serious cases, the inadvertent retention of a foreign object can cause the death of the patient.
If the patient survives and needs further treatment to correct the situation, it can still harm him physically and psychologically. It will also likely lengthen your recovery period. The additional, unplanned procedure also consumes time from medical staff, who could attend to other patients' affairs.
operation in the wrong place
An operation in the wrong place is avery serious but avoidablesentinel event. Wrong place surgery is defined as a healthcare professional performing an operation on the wrong place on a patient's body. The most common reasons for these types of occurrences are incomplete documentation or non-compliance with surgical protocol (which typically involves double-checking correct positioning and other critical information about the procedure). When an organization reports wrong-site surgery, one of the most common corrective actions is to require more than one physician to confirm the surgical site before allowing the procedure to begin.
suicide/self harm
Suicide is considered a sentinel event if it occurs on the health center premises or within 72 hours of the patient's discharge. Self-harm is considered a sentinel event when a patient self-harms while in a healthcare facility. These two eventsare considered avoidableand may reflect the quality and availability of mental health services in a health care setting.
attack
Physical harm, including rape, manslaughter, and other forms of violence, is considered a sentinel event if it results in death, serious temporary harm, or permanent damage. This could be a patient attacking another patient, a patient attacking a healthcare worker, or even a healthcare worker attacking a patient. Because attacks can encompass so many different situations, each incident report is an opportunity for the organization to reassess its policies.make the installation more secure.
Feuer
Fortunately, fires are quite rare in healthcare facilities; however, they are still possible. they are firegenerally avoidableand could be due to an electrical malfunction, human error, or a variety of other factors. Even if the fire is small, it poses a great risk to patients and medical personnel due to the heat and unexpected smoke inhalation. Most healthcare facilities implement a fire safety protocol and sprinkler systems to mitigate damage from accidental facility fires.
Medication/Error Management
medication errorsand medication management are considered sentinel events if failure results in death, permanent damage, or severe transient damage. Examples of associated harm may include coma, paralysis, or permanent loss of function as a result of the medication error. Medication error could be giving a patient the wrong drug or dosage, or not giving the patient the drug in a timely manner to prevent or mitigate harm.
Clinical alert response
Many medical devices have alarms that signal when a patient needs attention; clinical alarm response refers to medical personnel who appropriately respond to these alarms. These alarms often indicate that a patient needs further treatment or immediate attention, so it is important that they are monitored at all times.despite the fatigue of the alarmexperienced by many healthcare workers. Failure to respond to an alarm appropriately, resulting in death or harm to the patient, can be considered a sentinel event.
Sentinel Event Reports
Although not required by the organization itself, the Joint Commission encourages medical facilities to report all Sentinel events. However, if an incident occurs, the event may also be reported by the patient or the patient's family. On average, approximately 75% of Sentinel events are voluntarily reported by the facility itself, with the remainder being reported by patients and/or their families.
When a Sentinel event is reported, the Joint Commission initiates afull analysis and researchin the event. That helps to discoverthe cause of the failure or accidentand then evaluate strategies to prevent the event from happening again in the future. By reporting an incident to the Joint Commission, corrective actions can be determined, thereby reducing the number of Sentinel events at that facility in the future.
If you or your loved one experience a sentinel event, it is important to report it to the Joint Commission. The goal of the Joint Commission is to use these reports to discover potential breaches in security procedures and to train healthcare facilities to prevent these events in the future. Sentinel event reporting helps reduce the likelihood of the event happening again, so your report can help protect future patients from harm.
For example, one of Sentinel's most concerning events in the late 1990s and early 2000s was the delivery of a baby to the wrong family, but these incidents were reported to the Joint Commission. The Joint Commission was able to perform a root cause analysis and recommend ways to prevent this in the future. Today, the number of babies given to the wrong family is zero.
While the number of sentinel events per year is likely never to be zero, reducing these numbers and preventing recurrence can help keep patients safe for years to come. If you believe that you or a loved one experienced an unreported sentinel event,contact the Joint Commissionfile a report and help implement corrective actions as soon as possible.
FAQs
What defines a sentinel event? ›
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.
What is a sentinel event nursing quizlet? ›A Sentinel Event is defined by The Joint Commission (TJC) 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.
What are 3 examples 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 example? ›Suicide of any patient receiving care, treatment, and services in a staffed around-the clock care setting or within 72 hours of discharge, including from the hospital's emergency department (ED) is considered a Sentinel Event.
Which is an example of a sentinel event quizlet? ›A patient commits suicide. Patient suicide is a sentinel event.
What is a sentinel or never event? ›A Never Event is a medical error that is clear to identify and prevent but the consequences can be serious to a patient's health. On the other hand, a sentinel event is an event that in most cases starts as a Never Event but leads to a patient's death, permanent harm, or several temporary harms.
What is a sentinel event in nursing? ›A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event.
What is one example of a never or sentinel event in health care? ›Often called Never Events, these include errors such as surgery performed on the wrong body part or on the wrong patient, leaving a foreign object inside a patient after surgery, or discharging an infant to the wrong person.
Is a sentinel event an expected occurrence? ›Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof". They also include the following, even if death or major loss of function did not occur: Infant abduction. Release of an infant to an incorrect family.
Where is a sentinel event reported? ›Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission. Organizations benefit from self-reporting in the following ways: The Joint Commission can provide support and expertise during the review of a sentinel event.
What is a sentinel event review? ›
A sentinel event review (SER) is a system-based, multistakeholder review of an organizational error. The goal of an SER is to prevent similar errors from recurring in the future rather than identifying and punishing the responsible parties.
What is performed after a sentinel event? ›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.
What is a sentinel event in patient safety? ›A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event.
What is an example of a patient safety event? ›Patient Safety Event Reporting Policy #379
8) Rape or assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital.
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.
Which of the following is always true regarding a sentinel event? ›Which of the following is always true regarding a sentinel event? The occurrence requires an immediate investigative response; a sentinel event should be as high a priority as a reactive response to a sentinel event. A failure mode and effects analysis (FMEA) provides which of the following types of review?
What is a sentinel event prophecy quizlet? ›What is a sentinel event. An event that affects a patient causing death harm or intervention required to sustain life.
What are sentinel events in ambulatory care? ›A sentinel event is a patient safety event (not primarily related to the natural course of a patient's illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).
Is a close call a sentinel event? ›Patient Safety Event: An event, incident, or condition that could have resulted or did result in harm to a patient. Patient safety events include sentinel events, no-harm events, close calls, and hazardous condition.
Is a near miss fall a sentinel event? ›recurrence carries a significant chance of a serious adverse outcome. Such a near miss falls within the scope of the definition of a sentinel event but outside the scope of those sentinel events that are subject to review by The Joint Commission under its Sentinel Event Policy.
Is abduction a 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.
Is a pressure ulcer a sentinel event? ›1 In addition, the development of Stage 3 and 4 pressure ulcers (see the section below for definitions) is currently considered by The Joint Commission as a patient safety event that could be a sentinel event. Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill.
What is the sentinel event data? ›The sentinel event data represents aggregate data from comprehensive systematic analysis (typically a root cause analysis) received by the Joint Commission Office of Quality and Patient Safety from January 1, 2022 through December 31, 2022.
What is the difference between a sentinel event and a safety event? ›A No Harm Event is a patient safety event that reaches the patient but does not cause harm. A Sentinel Event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm.
What is the number one cause of sentinel events? ›According to the Joint Commission, the most common cause of sentinel events in healthcare includes unintended retention of a foreign object, fall-related events, and performing procedures on the wrong patient. Others include delay in treatment, medication error, and fire-related events.
What are the types of sentinel events? ›- Stage 3, 4, and unstageable pressure ulcer.
- Patient fall with serious injury or death.
- Unanticipated death with 48 hours of treatment.
- Unanticipated death.
- Wrong site surgery.
Unintended Retention of Foreign Object (URFO) is one of the most frequently reported sentinel events to The Joint Commission.
Who tracks sentinel events? ›By identifying causes, trends, settings and outcomes of sentinel events, The Joint Commission can provide critical information in the prevention of sentinel events to accredited health care organizations and the public.
How long to report in Sentinel? ›Within 48 hours of initial phone call to Comcare. Note: Sentinel will automatically send the written notification to Comcare when the Workplace Supervisor completes all the required actions in Sentinel. Reporting to ARPANSA is to be, in the first instance, within 24 hours of the accident.
What is the purpose of a sentinel event alert? ›Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences.
What is the most common patient safety incident? ›
Medication-related incidents are the most commonly reported incidents in healthcare. This includes administering the wrong dose, giving medication to the wrong patient, or omitting the dose.
What is an example of a patient incident? ›Wrong dose of prescription indicated. Wrong medication supplied. Incomplete or incorrect medication handoffs.
What is a serious safety event in healthcare? ›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 are examples of patient rights? ›A patient has the right to respectful care given by competent workers. A patient has the right to know the names and the jobs of his or her caregivers. A patient has the right to privacy with respect to his or her medical condition. A patient's care and treatment will be discussed only with those who need to know.
What is a patient safety event that did not cause harm as defined by the term sentinel event called? ›An Adverse Event is a serious, undesirable and usually unanticipated patient safety event that resulted in harm to the patient but does not rise to the level of being sentinel. A No Harm event is a patient safety event that reaches the patient but does not cause harm.
What sentinel event alert is physical and verbal violence against health care workers? ›The Joint Commission issues sentinel event alerts to raise awareness regarding risks in the health care setting. This alert highlights physical and verbal violence as a major problem in the workplace, particularly in areas such as the emergency department and inpatient psychiatric units.
What is the difference between a serious safety event and a sentinel event? ›A No Harm Event is a patient safety event that reaches the patient but does not cause harm. A Sentinel Event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm.
What is the difference between adverse event and sentinel event? ›An Adverse Event is a serious, undesirable and usually unanticipated patient safety event that resulted in harm to the patient but does not rise to the level of being sentinel. A No Harm event is a patient safety event that reaches the patient but does not cause harm.
What are sentinel events in anesthesia? ›The Joint Commission defines sentinel events as unexpected occurrences involving death or serious physical or psychological injury or the risk thereof. Such events are called “sentinel” because they signal the need for immediate investigation and response.
What is considered a serious safety event? ›A Serious Safety Event (SSE), in any healthcare setting, is a deviation from generally accepted practice or process that reaches the patient and causes severe harm or death.
Are all errors considered sentinel events? ›
investigation and response. occur because of an error, and not all errors result in sentinel events.
What are the top reasons for sentinel events? ›According to the Joint Commission, the most common cause of sentinel events in healthcare includes unintended retention of a foreign object, fall-related events, and performing procedures on the wrong patient. Others include delay in treatment, medication error, and fire-related events.
What is the most common type of medical error? ›Misdiagnosis, failure to diagnose, and delayed diagnosis are some of the most common types of medical errors. For example, doctors may fail to order diagnostic tests or interpret the results of a diagnostic test correctly.
Do sentinel events refer to expected deaths illnesses or major injuries? ›A sentinel event is a patient safety event (not primarily related to the natural course of a patient's illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).
Is infection a sentinel event? ›“Sentinel event” means an unexpected occurrence involving facility-acquired infection, death or serious physical or psychological injury or the risk thereof, including, without limitation, any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
What is a serious reportable event? ›An SRE is: An event that results in an adverse outcome for a patient, such as a doctor performing the wrong procedure. Identifiable and measurable. Influenced by the policies and procedures of the health care facility it happened in.
Is a fall a never event? ›As noted above, falls with injury are a serious reportable event for The Joint Commission and are considered a "never event" by CMS.