Sentinel Event Research Articles

Patient Readiness for Surgery: A Quality Improvement Initiative

ABSTRACTThe use of a surgical safety checklist can help prevent sentinel events; however, a lack of adherence to the checklist can result in inadequate preoperative patient readiness and negative outcomes. The purpose of this quality improvement project was to address preoperative concerns that prevent patient readiness in a military hospital. To change practice, the project involved the use of an evidence‐based practice model and Kurt Lewin's change theory. The primary investigator provided an educational initiative on the required checklist for perioperative personnel and collected data on key elements (ie, consent completion, laboratory test results, antibiotic availability, checklist completion) for 30 days after the initiative. Consent completion rates were 100% both before and after the intervention. Statistical analysis (chi‐square [χ2]) showed significant improvement for the remaining three elements. The results were the most significant for laboratory test results (χ21 = 33.496, P < .00001).

Challenges in transitioning from adolescent to Adult Mental Health Services for young adults with ADHD in Italy: an observational study.

Ensuring a successful transition to Adult Mental Health Services (AMHS) is fundamental for attention deficit/hyperactivity disorder (ADHD) patients to prevent adverse scenarios in adults (e.g., psychiatric disorders, substance or alcohol abuse). Yet, most European nations do not have appropriate transition guidelines and still fail to adequately support transition processes. This study aims to enquire about the current transition paths in Italy and the perceived experiences of the patients and their clinicians. The present observational study collected 36 interviews with young adults with ADHD who turned 18 between 2017 and 2021. Simultaneously, two questionnaires were filled in by the clinicians (both from paediatric and AMHS) who were involved in their transition paths. These tools collected information about the transition process, the services that cared for the young adults and well-being indicators such as impairment in daily life, employment status and the presence of sentinel events (e.g., critical stage accesses to the emergency room or hospitalizations). Successful and failed referrals were analysed. A referral to an AMHS was attempted for 16 young adults (8 before age 18 and 8 when turning 18), and 8 patients (22.2% overall) were successfully taken into the care of the AMHS. Twenty patients were not referred since it was deemed unnecessary (N = 6) or because of the lack of specialized services or compliance (N = 14). At the time of the interview, only nine participants were still under AMHS care. Of eleven individuals with a high need for care (identified by the level of impairment, support needs or sentinel events), five were not followed by a mental health professional at the time of the interview. For the majority of ADHD young adults, a transition path was never started or completed. While this is partly due to mild levels of impairment, in many cases it was difficult to find a service that could care for the adult patient. Only one out of four young adults are successfully transferred to AMHS care. Creating or improving evidence-based transition guidelines should be a priority of the public health system to ensure healthcare for as many patients as possible. The results of this study will converge towards the need for recommendations for the transition of services from adolescence to adulthood for young people with ADHD for Italian clinical practice.

Association Between Pandemic-Related Instructional Delivery Modifications and Emergency Medical Technician (EMT) First Attempt Pass Rates

Background: The COVID-19 pandemic represents a sentinel event for healthcare and healthcare education alike. Mandatory shutdowns of educational institutions, combined with increased demand for skilled healthcare personnel, highlighted pre-existing challenges surrounding how to maintain a stable workforce. To ensure continuity of educational opportunities, many emergency medical services (EMS) educational institutions were forced to modify existing learning method to digital learning formats. This emergent transition unearthed concerns regarding the impacts alternative learning methods would have on entry-level EMS providers' learning outcomes and overall competency levels. The objective of this study was to investigate the impact of alternative instructional methods used for EMT education during the COVID-19 pandemic. Methods: The study is a retrospective review of prospectively collected data for EMT candidates from a single community college-based EMT program who completed a first attempt of the National Registry EMS Certification examination for EMT candidates from course sections ending between January 1, 2019, and December 31, 2020. Historical pre-COVID first attempt exam outcomes were compared to the first attempt outcomes of two alternative instructional methods –Emergency Remote (ER) and COVID Distance Learning Hybrid (DL). Results: The outcomes of 237 EMT students were evaluated. Remote and COVID Hybrid DL models compared to the traditional pre-COVID learning format. There was no significant difference in first attempt pass rates between students who participated in traditional learning, the Emergency Remote model (1.53 odds ratio), or the Distance Learning model (2.98 odds ratio). Conclusions: This study suggests that virtual learning is at least as effective as traditional formats in preparing students for the NREMT examination. Additional research is warranted regarding best practices for applying virtual learning modalities in EMS education.

Therapeutic hypothermia: A descriptive, cohort study conducted over 10 years at a tertiary care public hospital.

Introduction. Therapeutic hypothermia (TH) reduces the risk of death or disability in children with moderate to severe hypoxic ischemic encephalopathy (HIE). Objective. To describe a population of patients with HIE that required TH and their course until discharge. Population and methods. Retrospective, descriptive, cohort study. All patients admitted to TH between 2013 and 2022 were studied. Epidemiological, clinical, monitoring, and treatment data were assessed, together with supplementary tests and condition at discharge. Risk factors were compared between deceased patients and survivors; and, among the latter, those requiring special healthcare needs (SHCN) at discharge. Results. A total of 247 patients were included. Mortality: 11%. Most common sentinel event: prolonged second stage of labor (39%). Treatment initiation: median of 5 hours of life. Seizures: 57%. Intravenous erythropoietin: 66.7%. Abnormal pattern in brain function monitoring: 52%. Normalization of monitoring: median of 24 hours. Pathological magnetic resonance imaging: 42%. Predictor variables of mortality: severe Sarnat and Sarnat staging and pathological ultrasound upon admission. Conclusion. The overall mortality rate was 11%. Referrals increased more markedly since 2018. The time of TH initiation was later than in previous reports. Severe neurological signs as per the Sarnat and Sarnat staging and a pathological baseline cranial ultrasound were independent predictors of mortality at discharge. Patients with SHCN at discharge showed a normalized tracing in the amplitude-integrated electroencephalography performed later. The most common finding in the magnetic resonance imaging was basal ganglia involvement. No statistically significant differences were observed in terms of clinical characteristics or complications among patients who received erythropoietin.

Developing Clinical Judgment During Transition to Practice With Rapid-Cycle Deliberate Practice Simulation.

New-to-practice nurses (NPNs) make more errors than their experienced peers, affecting patient safety and contributing to sentinel events. Additionally, new nurses have a high attrition rate in their first year of practice. Simulation-based education may bridge the gap between education and practice by supporting the development of clinical judgment of NPNs. With quality improvement methods, an intradisciplinary team implemented a quality improvement project to improve NPNs' clinical judgment skills. A multipatient simulation that used rapid-cycle deliberate practice gave NPNs an opportunity to refine clinical decision-making and communication skills. In total, 24 NPNs participated in the pilot simulation. Pre- and postsurvey scores using the simulation effectiveness tool-modified showed self-reported improvement in clinical judgment and communication skills, among other competencies. Rapid-cycle deliberate practice simulation may support the development of essential nursing competencies, along with increased confidence and enhanced psychological safety among NPNs. [J Contin Educ Nurs. 202x;5x(x):xx-xx.].

Disparities in Dual-energy X-ray Absorptiometry Scan Utilization Across Race/Ethnic Groups Before and After Hip Fractures.

Geriatric hip fractures are common and important sentinel events regarding bone health. Although dual x-ray absorptiometry (DEXA) scans are a standard method for determining bone density, differences in use among various race/ethnic groups around the time of hip fracture may reveal disparities within the healthcare system. The 2014 to 2016 Medicare Standard Analytic Files PearlDiver data set was used to identify geriatric patients sustaining hip fracture. From that cohort, those who had a DEXA scan before or after their fracture were defined. For the defined cohorts, patient age, sex, Elixhauser Comorbidity Index, race/ethnicity, and income (based on zip code) were defined and compared with univariate and multivariate analyses. Of 58,099 hip fracture patients, only 19.8% had had a DEXA scan before fracture and 3.9% of the remaining group had the DEXA scan after fracture. Of the hip fracture population, 91.0% identified as White and 9.0% as non-White (Native American, Black, Hispanic, Asian, or Other). Before hip fracture, controlling for other variables and compared with White patients, all non-White categories were at lesser odds of having had the DEXA scan. After hip fracture, Black, Hispanic, and other patients were also at lesser odds of having the DEXA scan. Using a large Medicare data set, controlling for patient age, sex, Elixhauser Comorbidity Index, and income marker, this study revealed disparities in DEXA scan utilization across race/ethnic groups before and after presenting with a hip fragility fracture. Identification of such disparities highlights the needs for improved medical access and care for this at-risk hip fracture population.

Systematic Root Cause Analysis of Retained Foreign Objects: A Descriptive Study of 1,371 Sentinel Events from 2010 to 2020 Using Data Analytics

Systematic Root Cause Analysis of Retained Foreign Objects: A Descriptive Study of 1,371 Sentinel Events from 2010 to 2020 Using Data Analytics

Peer review for handoff education in a transition to residency course: A prospective cohort study.

Association of American Medical Colleges (AAMC) and Accreditation Council for Graduate Medical Education (ACGME) mandate training in handoff delivery for students and residents. Communication errors, including errors during handoffs of patient care, account for over 2/3 of sentinel events. This study aims to assess the effectiveness of peer-assisted learning (PAL) in handoff education within a longitudinal framework. This study involved the analysis of fourth-year medical students (n = 67) enrolled in a transition to residency program designed to reinforce skills essential for success in internal medicine residencies. We modified the I-PASS handoff rubric for a single-encounter evaluation. Before attending the transitions of care workshop, students submitted one written handoff report. During high-fidelity simulation sessions, peers evaluated the written document as well as verbal handoffs, while faculty evaluated a recorded verbal version. The primary outcome measured was improvement in handoff quality and accuracy over time and secondary outcomes compared peer- and self-evaluations to faculty assessments. Overall, students demonstrated a statistically significant improvement in handoff quality and accuracy across all scoring criteria after completing the peer evaluation process. Peer evaluations did not demonstrate statistically significant differences in scores for quality or accuracy questions as compared to faculty. Peer evaluators effectively assessed handoff reports using the modified I-PASS checklist yielding outcomes similar to faculty while providing feedback. These findings provide exciting evidence that should prompt training programs to consider incorporating standardized peer review into handoff education for medical students and, potentially, residents. The detailed evaluation of individual handoff events fosters feedback skills essential for ongoing professional growth and clinical excellence.

Patient Falls Again Top Annual Sentinel Events List.

Events overall held steady after rising for several years.

Palliative Care in Advanced Kidney Disease: The Approach for a Nephrologist

ABSTRACT Advanced kidney disease presents a significant burden to patients, often leading to a complex array of symptoms and challenges that impact their quality of life. Palliative care (PC), with its focus on symptom management, communication, and holistic support, plays a crucial role in enhancing the well-being of these patients. This article explores the principles of PC in the context of advanced kidney disease, highlighting the need for early integration into standard nephrology care. It also discusses PC interventions such as symptom management, psychosocial support, advanced care planning (ACP), withdrawal of dialysis, and end-of-life care. Symptom management is an essential aspect of kidney-supportive care. The psychosocial burden of advanced kidney disease on the patient and the family needs to be adequately explored along with optimum utilization of local and institutional resources. The option of withdrawal of dialysis should be considered and discussed with patients where applicable. The Supreme Court has laid down guidelines for ACP which include both medical and legal processes to be followed. End of life is a sentinel event that needs adequate medical and nursing support which should be offered keeping in mind the principle of nonabandonment.

The role of CT imaging in proposed algorithm for managing post-operative hemorrhage after pancreaticoduodenectomy: case series

BackgroundPost-pancreatectomy hemorrhage (PPH) is among the most severe complications after pancreaticoduodenectomy. Gastroduodenal artery pseudoaneurysm rupture may prove fatal without expeditious invasive treatment, while other causes of PPH can often be treated medically. Pseudoaneurysms may be effectively managed with endovascular stenting or angioembolization techniques. CT imaging allows for non-invasive evaluation prior to intervention but may delay treatment and result in false-negatives. Materials and methodsPatients who developed PPH after pancreaticoduodenectomy at a high-volume institution over a 24-month span were included. Perioperative factors and clinical management data were analyzed to examine management and imaging utility. ResultsTwelve patients (thirteen bleeds) were evaluated. Six were extraluminal and suspicious for pseudoaneurysm rupture. Three of these bleeds were preceded by sentinel events. Obtaining CT imaging prior to interventional radiological management delayed treatment by a mean of 6.7 h. Four bleeds were treated with endovascular therapy. These were successful interventions without bleed recurrence. ConclusionsBased on the current findings and limited relevant literature, this manuscript presents recommendations for managing PPH as developed by interdepartmental consensus between surgery and interventional radiology.

Recent HIV infection and associated factors among newly diagnosed HIV cases in the Southwest Ethiopia Regional State: HIV case-based surveillance analysis (2019–2022)

BackgroundGlobally, there were an estimated 39 million people living with HIV with 1.3 million new HIV infections by the end of 2023. The Sub-Saharan Africa accounted 51% of new HIV infections. HIV case-based Surveillance collects data on newly diagnosed HIV cases, recent HIV infections, and other sentinel events, aiding evidence-based decision making. There is limited evidence on these in Ethiopia. The objective of this study is to determine the incidence proportion of recent infections and associated factors among newly diagnosed HIV cases and their distribution by person, place, and time in the Southwest Ethiopia Regional State.MethodsA retrospective analysis was conducted on HIV case-based surveillance dataset (July 2019 to June 2022) from the Southwest Ethiopia Regional State. Recent HIV infection is an infection that acquired within the last 12 months as diagnosed by Asante recency test kits. Data were analyzed using SPSS version 26. ArcGIS version 10.8 was used for mapping recent infections. Logistic regression was employed to identify factors associated with recent infections. In multivariable logistic regression analysis, variables with p-value < 0.05 and an adjusted odds ratio with 95% confidence interval were considered to declare significant association.ResultsA total of 1,167 newly diagnosed HIV cases (eligible cases) were identified. Among these, 786 (67.3%) recency tests were performed. The mean age of individuals with recent infection was 28.4 years. The proportion of recent infection is 89 (11.3%, 95% CI: 11.2, 11.5%). The highest proportion of recent infection is reported from the West Omo zone (42.9%), whereas 13.2% in Bench Sheko zone. Recent infection is significantly associated with age 15–24 years [AOR = 7.14, 95%CI: 2.89,17.57], age 25–34 years [AOR = 5.34, 95%CI: 2.20,12.94], females [AOR = 2.03, 95%CI: 1.26,3.25], and contact history with the index case [AOR = 0.48, 95%CI: 0.28, 0.83]. The incidence of recent infection increased from 86 (in 2019/20) to 132 (in 2022) recent infections per 1,000 newly diagnosed cases.ConclusionsRecent HIV infection is a public health concern in the Southwest Ethiopia Regional State with an increasing incidence. Targeted prevention efforts are necessary, especially for females and younger people.

A comparison of foot fractures relative to other fragility fractures: a review and analysis of the American Orthopaedic Association's Own the Bone Database.

Osteoporosis can clinically result in fragility fractures. Evidence regarding the risk factors and characteristics of foot fragility fractures compared to non-foot fragility fractures is limited. The American Orthopaedic Association's Own the Bone (OTB) is a bone health initiative with a substantial dataset. The purpose of this study was to examine and compare characteristics of patients presenting with isolated foot fragility fracture to those with a non-foot fragility fracture. Between January 2009 and March of 2022, 58,001 fragility fractures occurred that were included in this cohort. A total of 750 patients had foot fragility fracture(s) and 57,251 patients had a non-foot fragility fracture that included shoulder, arm, elbow, forearm, wrist, spine, ribs, pelvis, hip, thigh, knee, tibia/fibula, and ankle. Demographics, fracture history, bone health factors, medication history, and medicationuse for each patient were reported in the OTB database. This data was utilized in our secondary cohort comparative analysis of characteristics and the risk of future fractures between foot fragility fracture and non-foot fragility fracture groups. Foot fragility fracture patients have a significantly higher probability to be younger (66.9years old), female (91.5%), and have a higher BMI (28.3kg/m2) compared to non-foot fragility fracture (p < 0.0001) patients. Patients with a foot fragility fracture are nine times (OR = 9.119, CI = 7.44-11.18, p < 0.001) more likely to have had a prior foot fragility fracture. Young, female patients with a prior foot fragility fracture are at higher risk of a future foot fragility fracture, and this risk increased as BMI increased. Foot fragility fracture patients are more likely to be female and younger compared to patients with a non-foot fragility fracture. A foot fragility fracture is a sentinel event considering that a prior foot fragility fracture is strongly predictive of a subsequent foot fragility fracture. 3 (retrospective cohort).

Patient Safety Incidents in Operating Rooms Reported in the Past Five Years (2017-2021) in Korea.

Patient safety incidents in the operating room require special attention because they can cause catastrophic and irreversible conditions in patients. Although patient safety incidents have different characteristics, there may be similarities and patterns of risk factors that may be common. Therefore, this study analyzed factors associated with the PSIs by analyzing data from the Korean Patient Safety Reports from 2017 to 2019. The "Patient Safety Incidents Data from 2017 to 2021" systematically collected by the Korea Institute for Healthcare Accreditation, include patient safety incident reports from medical institutions. Data on 1140 patient safety incidents in the operating room were analyzed. They included patients' gender and age, Hospital size, Incident seasons, incident time, Incident reporter, incident type, Medical department, and Incident severity. The Incident severity was analyzed by dividing it into three stages: near miss, adverse event, sentinel event, which are applied by domestic medical institutions. The highest number of OR patient safety incidents were related to surgery and anesthesia. On analyzing the probability of adverse events based on near misses, the significant variables were patient gender, incident reporter, incident type, and Medical department. Additionally, the factors that were likely to precipitate sentinel events based on near misses were patient gender, incident time, reporter, and incident type. To prevent sentinel events in Patient safety incidents, female and during night shifts are required to pay close attention. Moreover, it is necessary to establish a patient safety reporting system in which not only all medical personnel, but also patients, generally, can actively participate in patient safety activities.

The Impact of Patient Education on Inpatient Fall Risk: A Review.

» Patient falls in the hospital are one of the leading sentinel events identified by the Joint Commission.» Hospital falls affect orthopaedic patients of older age at higher rates, and up to 34% of falls lead to injury such as fractures.» Patients often misperceive their fall risk, and modalities aimed at educating patients to address the incongruence between perceived and actual fall risk significantly reduce fall rate and injurious fall rate.» Adequate communication with patients and their families with the goal of educating them may diminish the physical, psychological, and emotional detriment to orthopaedic patients.

Infected pancreatic necrosis-Current trends in management.

Acute necrotizing pancreatitis is a common gastrointestinal disease requiring hospitalization and multiple interventions resulting in higher morbidity and mortality. Development of infection in such necrotic tissue is one of the sentinel events in natural history of necrotizing pancreatitis. Infected necrosis develops in around 1/3rd of patients with necrotizing pancreatitis resulting in higher mortality. So, timely diagnosis of infected necrosis using clinical, laboratory and radiological parameters is of utmost importance. Though initial conservative management with antibiotics and organ support system is effective in some patients, amajority of patients still requires drainage of the collection by various modalities. Mode of drainage of infected pancreatic necrosis depends on various factors such as the clinical status of the patient, location and characteristics of collection and availability of the expertise and includes endoscopic, percutaneous and minimally invasive or open surgical approaches. Endoscopic drainage has proved to be a game changer in the management of infected pancreatic necrosis in the last decade with rapid evolution in procedure techniques, development of novel metal stent and dedicated necrosectomy devices for better clinical outcome. Despite widespread adoption of endoscopic transluminal drainage of pancreatic necrosis with excellent clinical outcomes, peripheral collections are still not amenable for endoscopic drainage and in such scenario, the role of percutaneous catheter drainage or minimally invasive surgical necrosectomy cannot be understated. In a nutshell, the management of patients with infected pancreatic necrosis involves a multi-disciplinary team including a gastroenterologist, an intensivist, an interventional radiologist and a surgeon for optimum clinical outcomes.

Perspectives of Occupational Therapy Graduates on Sentinel Events During Transitions to Practice: A Phenomenographic Study

Perspectives of Occupational Therapy Graduates on Sentinel Events During Transitions to Practice: A Phenomenographic Study

Implementation of Cultural Awareness and Cognitive Bias Training Within Graduate Nursing Programs.

Cognitive bias negatively affects patient outcomes, resulting in medical errors, sentinel events, and legal claims. The brunt of bias-induced inequities and disparities has fallen on Black and Brown people, women, and the LGBTQ+ communities. Faculty training programs have rapidly increased in number, whereas student training has lagged. A three-part curricular series was developed for students seeking nurse practitioner (NP) training. The series addressed racial bias, microaggression, and gender bias using vignettes and guided pre- and debriefing. The series was initially implemented to 70 students from four different specialty areas of study. Students resoundingly reported the content as valuable and challenging and the environment as a safe space to learn, be vulnerable, and be empathetic to the experiences of others. This three-part series has been implemented across eight NP majors and has become a required component of the NP on-campus intensive experience. [J Nurs Educ. 2024;63(X):XXX-XXX.].

Falls in the hospital: An Italian clinical risk management perspective

Background Hospital falls are a frequent sentinel event worldwide, yet prevention remains challenging. There is a need to standardize hospital fall management in healthcare facilities. This study aimed to analyze policies and procedures used by Italian healthcare facilities to reduce hospital falls. Methods The Italian hospitals’ public procedures on patients’ falls issued between November 2011 and June 2022 were retrieved by a web search using the Google search engine and further evaluated according to their compliance with the 2011 Italian Ministerial recommendation for the prevention of patients’ falls. Results We found 37 official online procedures, of which 45.6% showed full compliance with the 2011 Ministerial recommendation. All the documents explicitly addressed the issue of identifying patient-related fall risk profiles, whereas 28 set appropriate environmental risk factors. More than 80% of the retrieved procedures used the Conley scale. Forty-three percent of the procedures did not provide for national monitoring and reporting of patient falls. Conclusions Public procedures for preventing patient falls in Italian hospitals are scarcely compliant with the 2011 Ministerial recommendation. Local monitoring, compliance, and reporting of hospital falls are needed to improve patient outcomes and reduce the risk of litigation for staff and organizations. Additionally, standardized tools for evaluating the risk of falls, healthcare professionals’ training, and implementing environmental prevention strategies are needed to contrast this issue.

Grading recommendations for enhanced patient safety in sentinel event analysis: the recommendation improvement matrix

ObjectivesThe goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due...