A sentinel event is "any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness".
Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The
Joint Commission (TJC) accreditation policies to help aid in
root cause analysis
In science and engineering, root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. It is widely used in IT operations, manufacturing, telecommunications, industrial process control, ...
and to assist in development of preventive measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed, and that undesirable trends or decreases in performance are caught early and mitigated.
Specific events requiring review
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
* Unexpected
death of an infant not born prematurely
* Severe
neonatal jaundice
* Surgery mistakes (wrong body part, wrong individual)
* Objects
left in a patient after surgery
*
Rape
Rape is a type of sexual assault involving sexual intercourse, or other forms of sexual penetration, carried out against a person without consent. The act may be carried out by physical force, coercion, abuse of authority, or against a person ...
at a healthcare facility
*
Suicide
Suicide is the act of intentionally causing one's own death.
Risk factors for suicide include mental disorders, physical disorders, and substance abuse. Some suicides are impulsive acts driven by stress (such as from financial or ac ...
at a healthcare facility, or within 72 hours of departure
* Receiving a blood transfusion of the wrong blood type
*
Radiation therapy
Radiation therapy or radiotherapy (RT, RTx, or XRT) is a therapy, treatment using ionizing radiation, generally provided as part of treatment of cancer, cancer therapy to either kill or control the growth of malignancy, malignant cell (biology), ...
to the wrong part of the body
* Radiation therapy 25% or more above the planned dose
* Any radiation dose over 15
Gy or resulting in permanent soft tissue damage (ie. skin or organ necrosis).
In addition to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis.
{{Bar chart
, title = Main Sentinel Events reported to the
Joint Commission in 2015
, label_type = Type of event
, data_type = Number of events
, data_max = 266
, label1 = Unintended Retention of a Foreign Body , data1 = 123 , comment1 = 13.14%
, label2 = Wrong–patient, wrong-site, wrong-procedure , data2 = 121 , comment2 = 12.93%
, label3 = Suicide , data3 = 98 , comment3 = 10.47%
, label4 = Fall , data4 = 95 , comment4 = 10.15%
, label5 = Delay In Treatment , data5 = 82 , comment5 = 8.76%
, label6 = Op/Post-op Complication , data6 = 82 , comment6 = 8.76%
Actions and reporting
Participation is necessary by the leadership of TJC accredited healthcare organizations and by the persons closely involved in the systems under review. Causal factors are analyzed, focusing on systems and processes, not individual performance. Potential improvements, called an "action plan", are identified and implemented to decrease the likelihood of such events in the future. Each accredited organization is encouraged, but not required, to report any sentinel event to The Joint Commission. However, the organization is expected to prepare a root cause analysis and action plan within 45 calendar days of the event. In addition, healthcare organizations are required to notify the
Food and Drug Administration
The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respo ...
(FDA) and device manufacturers within 10 days of a sentinel event caused by a medical device, according to the Safe Medical Device Act of 1990. Statistics of sentinel events are recorded and published by the FDA's
MedWatch program.
Advantages of reporting sentinel events to The Joint Commission are:
*Adding to the database with dissemination to other health care facilities, preventing other adverse events.
*Consultation with The Joint Commission on implementing the root cause analysis and action plan.
*Association with national accrediting body reassures the public that all steps are being taken to prevent a recurrence.
Joint Commission actions
After review of the accredited facility's report on the sentinel event, The Joint Commission issues an Official Accreditation Decision Report that may modify the organization's current accreditation status, assign an appropriate "measure of success", or a require follow-up survey within six months. A healthcare facility that fails to complete a root cause analysis of the sentinel event and action plan within the time frame can be placed on "Accreditation Watch" by the Joint Commission, a status that can be publicly disclosed. The Joint Commission disseminates "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence.
[Joint Commission on Accreditation of Healthcare Organizations]
Sentinel Event Alerts
/ref>
Further nursing research is ongoing at a number of "magnet" hospitals in the United States, especially to reduce the number of patient falls that may lead to sentinel events.
References
External links
TJC Sentinel Events Policy and Procedure
Healthcare in the United States
Nursing in the United States