Sentinel events in healthcare: a quick synopsis
Dr. Aditi Sheth (????? ???) MBBS ???????????
??????? Manager Safety Solutions- Indegene | Bookworm | 900+ Certificates | PBRER | Aggregate reports | Artificial Intelligence | Trained Psychologist | Introvert | Dog parent | ISFJ |29K+| MBBS MBA MPH | ?????? ????
I thought sentinel events aka never events are critical in healthcare and a very short introduction would be worth of 5-7-10 minutes of your day!!
You can see the vivid example of such events and response in HotStar original 'Human' as well!
Without much adieu, let me start here:
? The term sentinel refers to a system issue that may result in similar events in the future.
? Can result in death, permanent harm, or severe, temporary harm.
? 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.
? The phrase ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.”
-Sentinel events may include:
Sentinel events cause significant morbidity or mortality and are possibly preventable.
? Preventable, serious, and unambiguous adverse events that should never occur.”
? These events are also termed as never events since they should never occur.
? Previously, sentinel events included events that occurred only to patients.
? In 2013, the concept was expanded to include “harm events” to the staff, visitors, and vendors on the organization’s premises.
Classification of sentinel events:
Serious reportable events can be classified into the following categories:
1.Surgical
2.Device/ product
3.Care management
4.Environnmental
5.Patient protection
6.Radiologic event
7.Criminal events
Sentinel events are systemic issues which may lead to same errors in the future again if not corrected.
Examples of sentinel events:
? Suicide during treatment or within 72 hours of discharge
? Unanticipated death during care of an infant
? Abduction while receiving care
? Discharge of an infant to the wrong family
? Hemolytic transfusion reaction due to blood transfusion with major blood group incompatibilities
? Surgery on the wrong individual or wrong body part
? Retained foreign body after surgery
? Severe neonatal jaundice (bilirubin >30 mg/dl)
? Prolonged fluoroscopy with very high or inappropriate dose or to the wrong site
? Fire during direct patient care caused by hospital equipment
? Intrapartum maternal death
? Unanticipated severe maternal morbidity resulting in permanent or severe temporary harm
? Rape
? Falls
? Delay in treatment
? Medication errors
? Criminal events
Response to a sentinel event:
? The reporting organization should prepare and submit a thorough root cause analysis and action plan (RCA2) within 45 days of the sentinel event.
? The process should commence within 72 hours of the event.
? The hospital must review all sentinel events.
? All accredited hospitals are encouraged but not obligated to report to the Joint Commission every sentinel event.
? All healthcare organizations should have a policy for responding to a sentinel event.
The steps in an RCA include:
? Identifying the team
? Information gathering
? Organizing information
? Identifying contributing factors
? Drilling down to the root cause.?
领英推荐
An appropriate response to a sentinel event:
? Stabilize the patient
? Disclose the event to the patient and family
? Provide support for the family and staff involved
? Notification to the hospital leadership
? Immediate investigation
? Comprehensive systematic review
? Root cause analysis (RCA) for identifying the causal and contributory factors
? Strong corrective actions to eliminate the root cause and prevent similar future events
? Establish a timeline for the implementation of corrective actions
? System improvement
The RCA- Root Cause Analysis for sentinel events:
? The reporting organization should prepare and submit a thorough root cause analysis and action plan within 45 days of the sentinel event.
? The process should commence within 72 hours of the event.
? The steps in an RCA include identifying the team, information gathering, organizing information, identifying contributing factors, and drilling down to the root cause.
? The RCA is asking a series of “why” questions until the root systemic causal factor(s) that culminated in the sentinel event is identified.
? The RCA should focus on vulnerabilities from systems and processes, not on the individual(s).
? It identifies the risk points and their potential contributions. Various root causes can be related to communication, equipment, environmental, human, process, staff, supervisory, team, and culture. Several attempts to improve the RCA process have been developed to formulate effective solutions.
What is root cause analysis and action (RCA2)? Why it matters?
? Emphasis on the action steps which are needed after the analysis is completed.
? After the cause is identified, solutions to the problem or error should be recognized and implemented.
? RCA2 differs from other patient safety tools like the failure mode effect analysis (FMEA) and the situation background assessment recommendation (SBAR).
? FMEA is a systematic, proactive method for identifying potential risks and assess their impact before harm has occurred. SBAR is a framework for communication between team members about a patient's condition.
? An RCA2 must be thorough and credible.
The sequential steps in an RCA2 are:
2. Gathering all the relevant information
3. Organizing the collected information
4. Identifying the root cause
5. Developing a strong action plan
6. Reporting
RCA2 action items examples:?
? The action hierarchy of RCA2 helps in identifying the corrective actions that will have the strongest effect on an effective and sustained system change.
? More strong actions require less reliance on human factors and memory.
? The most effective actions accommodate or control the limitations of human behavior.
? Stronger actions should be prioritized to sustain the system change.
? Things like forcing functions, barcode for medication administration, process or equipment standardization, pre-procedural timeout with all members, and simplification of the process are examples of stronger actions. Checklists serve to force improved function and utilize the principles of human factor engineering.
? One of the most critical surgical safety measures is the timeout process, which involves a pause before the surgery commences involving all team members. This process occurs before surgery begins with the patient inside the operating room to ensure that the correct patient, the correct procedure, and the correct site are verified to minimize mistakes.
In the end,
Some take home/ miscellaneous facts about sentinel events:?
? Sentinel events are preventable, serious, and unambiguous adverse events that should never occur.” These events are also termed as never events.?
? The reporting organization should prepare and submit a thorough root cause analysis and action plan (RCA2) within 45 days of the sentinel event.
? The process should commence within 72 hours of the event.
? The hospital must review all sentinel events.
? All accredited hospitals are encouraged but not obligated to report to the Joint Commission every sentinel event.
? All healthcare organizations should have a policy for responding to a sentinel event.
? The great majority of sentinel events occur in a medical/surgical hospital setting, followed by psychiatric hospitals (including psychiatric units and clinics) and emergency departments.
? The most common sentinel events are wrong-site surgery, foreign body retention, and falls.
? 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.
? Sentinel Event Measure of Success (SEMOS): SEMOS is a quantifiable measure to evaluate if the action plan was effective and sustained.?
So, that's it. Just a little synopsis about a critical concept in healthcare.
Please let me know how you feel/ share your thoughts in comments section.
Have a happy week ahead!