Patient Safety / Quality

Responding to a sentinel event

Each year, medical errors result in 44,000 to 98,000 deaths in the United States. This is not a news bulletin; these statistics were revealed nearly a decade ago by the Institute of Medicine in its seminal report To Err is Human: Building a Safer Health System. Since then, studies show that medical errors are the eighth leading cause of death in this country, killing up to 195,000 Americans every year.

Despite the hard work ongoing nationwide to analyze and reform healthcare systems and thus improve safety, severe errors or sentinel events still occur—and they can happen in any facility at any time. No organization or individual is immune. Sentinel events aren’t confined to substandard organizations. Many involve highly respected healthcare systems and practitioners.

This article defines a sentinel event, explains why sentinel events may occur, and describes ways to handle them.

Defining a sentinel event
Sentinel events are so named because they indicate the need for immediate investigation and response. The Joint Commission defines a sentinel event as: “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.”

The Commission points out that the term sentinel event isn’t synonymous with medical error. Not all sentinel events stem from an error, and not all errors lead to sentinel events. Accredited healthcare organizations are required to define a sentinel event in a way consistent with the Commission’s definition and to set a policy for identifying, reporting, and managing such an event. (See Categorizing sentinel events in the downloadable pdf available at the bottom of this page.)

Common sentinel events
From January 1995 through September 2007, the Joint Commission reviewed 4,693 sentinel events. It found that the top three sentinel events were:


  • wrong-site surgery (13.1%)
  • suicide (12.2%)
  • operative and postoperative complications (11.9%).

The Joint Commission’s universal protocol is designed to prevent wrong-site, wrong-procedure, or wrong-patient surgery. Nonetheless, for each hospital accredited by the Commission since 2004, wrong-site surgery was the leading sentinel event reported.
Wrong-site surgery exemplifies how a sentinel event can be linked to a breakdown in safety systems and communication. When evaluating system safeguards to prevent wrong-site, wrong-procedure, or wrong-patient surgery, organizational leaders need to ask such questions as:

  • Is there a problem with our policies or procedures?
  • Does our system have adequate built-in redundancies and safeguards for practitioners to effectively double-check the correct site preoperatively?
  • What orientation and training processes are related to the universal protocol? Are all the right people participating?
  • Are we performing periodic quality checks to determine whether the universal protocol is acceptable and being followed?

Why do sentinel events occur?
Most sentinel events result from systemic problems rather than the mistake or failure of a single individual. Inadequate communication among healthcare providers is the number-one root cause of sentinel events. In 2006, the second leading root cause was incorrect assessment of a patient’s condition; the third leading cause was inadequate leadership, orientation, or training.

Causes that may contribute to sentinel events include greater patient acuity and multiple comorbidities, greater dependence on medical technology, reduced lengths of stay, and shortages of nurses and other healthcare workers (which may decrease caregiver continuity). Also, after a hospital stay, the patient’s care may need to be coordinated with other departments, such as rehabilitation, long-term care, or home healthcare services; these multiple “hand-offs” of communication about the patient’s plans of care within a compressed period may set the stage for a sentinel event.

Handling a sentinel event
A sentinel event can be seen as a set of concentric circles, with the specific patient situation in the innermost circle and the entire healthcare system in the outermost circle. When an untoward outcome or a question of inappropriate care arises, healthcare professionals first must attend to the innermost circle—the patient’s safety and well-being. 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. Each healthcare organization has a policy regarding disclosure of adverse events to patients and families. If you don’t know your organization’s specific policy, refer to the policy manual or risk management department.

Root-cause analysis and action plan
The Joint Commission requires that organizations conduct a root-cause analysis to identify contributing factors within 45 days of a sentinel event or becoming aware of the event. This analysis focuses on systems and processes, not individual performance. All persons involved with the event in any way should participate in the analysis, as each may have important insights and observations. The sooner root-cause analysis takes place, the better—while the circumstances are fresh in participants’ minds. (See Helping the helpers in the downloadable pdf available at the bottom of this page.)

Root-cause analysis digs progressively deeper into the event, repeatedly asking why the event occurred and exploring in depth the circumstances that led to it, to determine where improvements can be made. The analysis may identify common and special causes, leading to implementation of an action plan for strategies to reduce the risk of similar events. Organizational leaders and risk managers should determine whether the event must be reported to the Joint Commission or other entity, such as a state healthcare regulatory agency.

The organization must submit its root-cause analysis and action plan to the Commission within 45 days of the event. The action plan should describe the organization’s risk-reduction approach, set a definitive timeline, assign responsibility for implementation and oversight, specify pilot testing as appropriate, and delineate strategies for measuring the plan’s effectiveness. In addition to addressing the innermost concentric circle of the sentinel event, the plan should spiral out to the larger circles enclosing the entire organization—even, in some cases, to other healthcare systems.

If the sentinel event must be reported to the Commission or other entity, representatives of these groups might visit the facility to check on compliance and adherence to the action plan. Ordinarily, the Commission doesn’t conduct an on-site review unless it finds a potential ongoing immediate threat to patient health or safety or potentially significant noncompliance with its standards. Nonetheless, healthcare organizations should always be ready for regulatory-body inspection and review.

Reporting sentinel events and their root-cause analyses and action plans to the Commission broadens the Commission’s sentinel event database. This, in turn, enhances knowledge about sentinel events and helps reduce the risk of these events happening in other facilities.
The Joint Commission publishes sentinel event alerts that identify specific sentinel events, along with their common underlying causes and steps to prevent them. Organizational leaders should share these alerts with staff to promote education and incident prevention.

Toward a culture of safety
Despite everyone’s best intentions, not all sentinel events can be prevented. But sustaining a culture of safety and promoting continual performance improvement can help prevent adverse outcomes. Facility leaders should ensure that staff members feel empowered to share their ideas for error prevention, report errors and near-misses, and question any practitioner or stop any process that imperils patient safety.

Barbara C. Sorbello is the Administrative Director of Acute Care Services at Bon Secours St. Francis Medical Center in Midlothian, Virginia.

Selected references
Buerhaus P. Lucian Leape on patient safety in US hospitals. J Nurs Scholarsh. 2004;36(4):366-370.

Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999. www.nap.edu/catalog.php?record_id=9728. Accessed September 3, 2008.

Joint Commission. Sentinel event policy and procedures. www.jointcommission.org/SentinelEvents/PolicyandProcedures/se_pp.htm. Accessed September 3, 2008.

 

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