What Is a Sentinal Event?
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 any of the following:
- Permanent harm
- Severe temporary harm and intervention required to sustain life
An event can also be considered sentinel event even if the outcome was not death, permanent harm, severe temporary harm.
In shorthand, a sentinal event is an unexpected occurrance that causes some patient harm.
The Joint Commission, a health-care accrediting agency, adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events. Data for sentinal events in 2014 has just been released.
What Are the Goals of the Sentinel Event Policy?
The Joint Commission's Sentinel Event Policy has four goals.
- To have a positive impact in improving patient care, treatment, and services, and in preventing unintended harm.
- To focus the attention of a hospital or other health care facility that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions, and active failures in defense systems, or hospital culture), and on changing the hospital's culture, systems, and processes to reduce the probability of such an event in the future.
- To increase the general knowledge about patient safety events, their contributing factors, and strategies for prevention.
- To maintain the confidence of the public, clinicians, and hospitals that patient safety is a priority in accredited hospitals and health care facilities.
What Happened in 2014?
"In 2014 the leading root causes and contributory factors are examples of cognitive failures,” says Ronald Wyatt, M.D., M.H.A., medical director, The Joint Commission. “Cognitive failure is preventable and safety-critical industries take a systems view. Health care organizations must focus on factors that influence errors and operationalize strong corrective actions aimed at improving working conditions and eliminating all preventable injury, harm and death.”
As you can see from the illustration, the root cause of over 50% of all sentinel events was some combination of leadership failures, communication errors, and/or supervision mistakes. The conclusion is that many unnecessary harms are preventable if we refocus on simple managment and communication issues. Many catastrophic "medical" mistakes aren't medical at all -- they are simple human factors failures.
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