Sentinel Events/Patient Safety Events.

Abstract

1. Richard E. McClead, MD, MHA* 2. Michael Brady, MD* 1. *The Ohio State University, Nationwide Children’s Hospital, Columbus, OH. 1. 1. Throop C, 2. Stockmeier C. SECsm & SSERsm Patient Safety Measurement System for Healthcare . Throop C, Stockmeier C. Virginia Beach, VA: Healthcare Performance Improvement, LLC; 2009. Available at: http://hpiresults.com/docs/PatientSafetyMeasurementSystem.pdf. Accessed July 18, 2016 2. 1. Kimberlin DW, 2. Brady MT, 3. Jackson MA, 4. Long SS Salmonella Infections . In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book®: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:695–701 3. 1. Muething SE, 2. Goudie A, 3. Schoettker PJ, 4. et al Quality Improvement Initiative to Reduce Serious Safety Events and Improve Patient Safety Culture . Muething SE, Goudie A, Schoettker PJ, et al. Pediatrics. 2012;130(2):e423–e431 [OpenUrl][1][Abstract/FREE Full Text][2] In 1996, the Joint Commission (TJC) adopted a formal policy regarding serious adverse patient events, known as sentinel events. The purpose of this sentinel event policy was to help hospitals experiencing such events improve patient safety. TJC defines a sentinel event as a “patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches the patient and results in any of the following: 1) death; 2) permanent harm; or 3) severe temporary harm.” TJC also lists a number of other conditions that are sentinel (Table) because they require immediate investigation and response by the hospital, and these investigations and responses are subject to review by TJC for appropriateness. View this table: Table. Definition of Sentinel Events TJC considers sentinel events as patient safety events that result in patient harm. However, not all sentinel events occur because of a medical error and not all harm that results from medical errors are sentinel events. The Solutions for Patient Safety (SPS) National Children’s Network of more than 90 children’s hospitals is focused on reducing patient harm that results from adverse patient safety events. SPS uses the Healthcare Performance Improvement LLC (HPI) (Virginia Beach, VA) classification of patient safety events. In contrast to sentinel events that are identified by event type, the HPI classification is outcome-based. This classification schema is described in the white paper by Throop and Stockmeier. HPI describe 3 types of patient safety events: 1) serious … [1]: {openurl}?query=rft.jtitle%253DPediatrics.%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2011-3566%26rft_id%253Dinfo%253Apmid%252F22802607%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=130/2/e423&atom=%2Fpedsinreview%2F37%2F10%2F448.atom