Sentinel Events

PRESENTATION ON
SENTINEL EVENT (CQI 9)
CAHO ADVANCED GROUP 4 Faculty:

Dr. Vijay Agarwal
Dr. Hemanta Kumar,
Dr. Suneel C
Reviewed by: Dr. Mukul Lal Mundkur
Dr.Lallu Joseph Mr. Vinod Kumar
Secretary General Mr. Souvik Das, Ms. Niyati Maun
CAHO Dr. Jeet Patwari
Mr. Vinod Kumar
Dr. Joseph Fidelis
CAHO Advanced Group 4
DEFINITIONS OF SENTINEL EVENT: Sentinel Event is an

unexpected Event happening at the hospital which involving
death or serious physical damage (loss of limb or function)
or psychological injury, or “the risk there of”.
“Risk there of” is defined as any variation in a process for

which a recurrence carries a significant chance of an
adverse outcome
NABH 4th Edition (Standard & Objective Element)
LIST OF SENTINAL EVENTS :-
SURGICAL EVENTS:-
 Surgery performed on the wrong body part
 Surgery performed on the wrong patient.
 Wrong surgical procedure performed on the wrong patient.
 Patient death during or immediately post surgical procedure.
 Retained swab or instruments in the patient discovered immediately post surgical

procedure
 Damage to structure (eg. Ureter, bowel, vessel).
 Delayed or missed diagnosis (eg. ectopic pregnancy).
 Failed procedures (eg. abortion, sterilization)
 Unplanned return to theater.

DEVICE OR PRODUCT EVENTS:
Patient death or serious disability associated with the –
 The use of contaminated drug, devices or products.

 The use or function of a device in a manner other than the devices intended
use.
 The failure or breakdown of a device or medical equipment.
PATIENT PROTECTION EVENTS:
 Discharge of an infant to the wrong person.

 Patient death or serious disability associated or elopement from the heath care
facility.
 Patient suicide, attempted suicide or deliberate self harm resulting in serious
disability.
 Intentional injury to a patient by a staff member, another patient, visitors or others.
 Any incident in which a line designated for oxygen or other care to be delivered to
a patient contains wrong gas or is contaminated by toxic substances.
 Nosocomial infection or disease causing patient death or serious disability.
ENVIRONMENTAL EVENTS:
Patient death or serious disability while in HCO associated with-

 Burn from any source.
 A slip, trip or fall.
 An electrical shock.
 Restraint.
CARE MANAGEMENT EVENTS :
 Patient death or serious disability associated with hemolytic reaction due

to administration of ABO- Incompatible blood or blood products.
 Maternal death or serious disability associated with labour delivery or
delivery in low risk pregnancy.
 Medication error leading to the death or any serious disability of patient
due to incorrect administration of drugs.
---Omission.
---Wrong Dosage.
---Wrong Dose preparation
---Wrong time.
---Wrong rate of administration.
---Wrong administration technique.
---Wrong patient
 Patient death or serious disability associated with avoidable delay.
--- in treatment.
--- in response to abnormal test results.
CRIMINAL EVENTS:
 Any criminal instance of care by or provided by an individual

impersonating a clinical member of staff (Doctor /Nurse).
 Abduction of patient.
 Sexual assault on a patient within or on grounds of the health care.
 Death or significant injury of a patient or staff member resulting from a
physical assault or other crime that occurs within the grounds of the
heath care organization.
OTHER EVENTS :
 Maternal death ( due to any cause)/ Death on the OT table.

 Blood loss > 1500 ml
 Caesarian section followed by hysterectomy.
 Anaesthesia related complication.
 Pulmonary embolism
 Neonatal death.
Incident Reporting Form
Root Cause Analysis: A "Root Cause Analysis" is a process

for identifying the basic or causal factor(s) that underlie
variation in performance including the occurrence or possible
occurrence of a Sentinel Event.
PROCEDURE FOR IDENTIFYING AND RESPONDING TO SENTINEL EVENTS
• Reporting Mechanism: If any individual in the Hospital (including, but not limited to,
any individual employed by the Hospital, any individual who independently contracts with
the Hospital to provide health care services to patients at the Hospital, any member of
the Hospital’s Medical Staff, and any allied health care professional) discovers, witnesses,
has knowledge of or otherwise becomes aware of any unexpected occurrence that is a
possible Sentinel event must report to safety committee or any senior official of the
hospital
Completion of Root Cause Analysis and Action Plan: The committee shall
investigate and understand the causes that underlie the event within seventy-two (72)
hours and complete a thorough and credible Root cause analysis and resulting Action
Plan describing the Hospital’s risk reduction strategies, within 15 days of the known
occurrence of the Sentinel Event.
Report: The committee shall after completing the Root Cause Analysis and Action Plan,
produce full documentation of the Root Cause Analysis and Action Plan to head of the
Hospital. The head of the hospital shall subsequently direct the Root Cause Analysis and
Action Plan to be reported to and thoroughly reviewed by the Hospital’s other relevant
committees if deems appropriate
Sentinel Events reported, collected and analyzed within the

defined timeframe
Number of sentinel events reported, Number of sentinel events reported ,collected and
collected and analyzed within the analyzed within the defined timeframe
defined timeframe 100
Number of sentinel events reported, collected
and analyzed
Number of sentinel events reported, collected and analyzed within

the defined timeframe
80.0%
71.4%
70.0%
62.5%
60.0%
50.0%
50.0% 44.4%
40.0% Number of sentinel events reported, collected and

33.3%
analyzed within the defined timeframe
28.6%
30.0% 25.0%
20.0%
10.0%
0.0%
Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18

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PRESENTATION ON

SENTINEL EVENT (CQI 9)

CAHO ADVANCED GROUP 4 Faculty:

DEFINITIONS OF SENTINEL EVENT: Sentinel Event is an

“Risk there of” is defined as any variation in a process for

 Surgery performed on the wrong patient.

 Wrong surgical procedure performed on the wrong patient.

 Patient death during or immediately post surgical procedure.

 Retained swab or instruments in the patient discovered immediately post surgical

 Damage to structure (eg. Ureter, bowel, vessel).

 Delayed or missed diagnosis (eg. ectopic pregnancy).

 Failed procedures (eg. abortion, sterilization)

 Unplanned return to theater.

Patient death or serious disability associated with the –

 The use of contaminated drug, devices or products.

 Discharge of an infant to the wrong person.

Patient death or serious disability while in HCO associated with-

 Patient death or serious disability associated with hemolytic reaction due

 Any criminal instance of care by or provided by an individual

 Maternal death ( due to any cause)/ Death on the OT table.

Incident Reporting Form

Root Cause Analysis: A "Root Cause Analysis" is a process

PROCEDURE FOR IDENTIFYING AND RESPONDING TO SENTINEL EVENTS

Sentinel Events reported, collected and analyzed within the

Number of sentinel events reported, collected and analyzed within

40.0% Number of sentinel events reported, collected and

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