Sentinel Events in Healthcare

Abstract

In this article we discussed Patient Safety and reporting of adverse events in healthcare organizationssentinel event and rootcause analysis, which lready became an important compenent in the new version of JCI accreditation system. Sentinel Event is an unexpected occurrence involving death, serious physical or psychological injury or risk thereof, and any event that might cause embarrassment or risk to the hospital with potential legal ramifications and/or medical inquiries or coverage. The phrase “or the risk thereof “includes any outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. Serious injury includes but is not exclusive to: an unanticipated death or major permanent loss of limb or function, not related to the natural course of the patient’s illness or underlying condition, infant abduction or discharge to the wrong family, patient suicide in hospital, rape of a patient, staff or visitor, significant hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities, surgery on the wrong patient or body part and significant Medication errors. In a sentinel event identification and investigation, we must apply root-cause analysis. Root Cause Analysis is a process for identifying the basic or casual factors that underlies variation in performance, including the occurrence or possible occurrence of a sentinel event. It focuses primarily on systems and processes not individual performance. It progresses from special causes in clinical processes to common causes in organizational processes and identifies potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future, or determines, after analysis, which no such mprovement opportunities exist.