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Sentinel event

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Dr.Kirti Choukikar
Dr.Kirti Choukikar

Sentinel events are unexpected occurrences in healthcare settings that result in death or serious injury and are more severe than medical errors. They include wrong-site surgeries, hospital-acquired infections, and infant abductions. The Joint Commission defines and tracks sentinel events to conduct root cause analyses and prevent future occurrences. Hospitals must analyze causes and create action plans when sentinel events happen to improve patient safety.

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SENTINEL EVENTS 1. 2. 3. 4. 5. 6. 12040141014 DEEVYA GAIKWAD 12040141017 AFSHEEN IRANI 12040141019 KIRAN KAUSHIK DASH 12040141020 KIRTI CHOUKIKAR 12040141021 RASHI THAPER 12040141022 STUTI SANGADA
SENTINEL EVENTS  A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.  Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures.  The Joint Commission tracks events in a database to ensure events are adequately analysed and undesirable trends or decreases in performance are caught early and mitigated.
Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof" and all of the following, even if the outcome was not death or major permanent loss of function:  Infant abduction, or discharge to the wrong family.  Unexpected death of a full-term infant.  Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).  Surgery on the wrong individual or wrong body part.  Instrument or object left in a patient after surgery or another procedure.  Rape in a continuous care setting.  Suicide in a continuous care setting, or within 72 hours of discharge.  Hemolytic transfusion reaction due to blood group incompatibilities.  Radiation therapy to the wrong body region or 25% above the planned dose.
Event types- NABH  Surgical events ( wrong body part/ patient/ procedure, retained instrument, death during the procedure, anesthesia related events)  Device or Product events (contaminated drugs and device, unintended use, breakdown or failure)  Patient protection events (infant discharge, elopement, suicide, attempted suicide, self-harm, intentional injury, nosocomial infection, medical gas )  Environmental events ( burn, slip, trip, fall, electric shock, use of restrains and bed rails)  Care management events (hemolytic reaction, maternal death, medication errors, delay in response)  Criminal events (impersonation, abduction, sexual assault, physical assault on the grounds of healthcare facility)
DIFFERENCE BETWEEN MEDICAL ERROR & SENTINEL EVENT MEDICAL ERROR  44,000 AND 98,000 AMERICANS DIE EACH YEAR  COMMON MEDICAL ERRORS  INCORRECT ADMINISTRATION OF • • MEDICATION  DOSAGE OR ROUTE OF ADMINISTRATION  FAILURE TO PRESCRIBE OR ADMINISTER CORRECT DRUG  USE OF OUTDATED DRUGS  FAILURE TO OBSERVE CORRECT TIME  LACK AWARENESS OF ADVERSE EFFECTS.  HARD TO READ HANDWRITTEN ORDERS  DIFFERENT DRUGS  DRUG ALLERGIES • SENTINEL EVENT: DEATH PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK • • • • • • • LOSS OF LIMB OR FUNCTION SUICIDE RAPE INFANT DEATH INFANT DISCHARGED TO WRONG PARENTS SURGERY ON WRONG PATIENT, OR BODY PART INCORRECTLY MATCHED BLOOD TRANSFUSION 1,900 SENTINEL EVENTS REVIEWED BY THE JOINT COMMISSION SINCE JANUARY 1995 • • • • PATIENT SUICIDE ACCOUNTED FOR 16.5% OF THE ERRORS OPERATIVE/POST-OPERATIVE COMPLICATION – 12.3% WRONG-SITE SURGERY – 11.7 MEDICATION ERROR – 11.5
SENTINEL EVENT POLICY To have a positive impact in improving patient care, treatment, and services and preventing sentinel events. To focus the attention of a disease-specific care program that has experienced a sentinel event. Understanding contributed factors to an event (such as underlying causes, latent conditions, and active failures in defense systems or organizational cultures). Disease-specific care program’s systems, culture, and processes to reduce the probability of such an event in the future. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention. To maintain the confidence of the public and certified programs in the certification process.
EXPECTATIONS FOR ORGANIZATIONS REPORTING: ROOT CAUSE ANALYSIS • PROCESS TO IDENTIFY BASIC OR CAUSAL FACTORS OF SENTINEL EVENTS CURRENT OR IN FUTURE ACTION PLAN • PLAN TO IDENTIFY STRATEGIES TO IMPLEMENT REDUCED RISK OF SENTINEL EVENTS SURVEY PROCESS • EVALUATE THE FACILITIES COMPLIANCE WITH APPLICABLE STANDARDS • SCORE PERFORMANCE
Sentinel Event is Identified: Inform the CEO Sentinel event identified Reported to the Joint Commissio n Review Process for responding to Sentinel event Interview Leaders Root Cause Analysis
• IN SUMMARY • • SENTINEL EVENT: • UNEXPECTED • • DEATH • • LOSS OF LIMB OR FUNCTION SUICIDE RAPE INFANT DEATH INFANT DISCHARGED TO WRONG PARENTS SURGERY ON WRONG PATIENT, OR BODY PART INCORRECTLY MATCHED BLOOD TRANSFUSION POLICY: • IMPROVING • • • • • • PATIENT CARE TREATMENT SERVICES PREVENTING SENTINEL EVENTS FOCUS ON DISEASE SPECIFIC CARE INCREASE KNOWLEDGE CLASSIFY AND RESPOND TO SENTINEL EVENT • • • PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK • • • • • • REPORTING: • ROOT CAUSE ANALYSIS ACTION PLAN IMPLEMENT IMPROVEMENTS MEDICAL ERROR • INCORRECT ADMINISTRATION OF MEDICATION • • • • • DOSAGE OR ROUTE OF ADMINISTRATION FAILURE TO PRESCRIBE OR ADMINISTER CORRECT DRUG USE OF OUTDATED DRUGS FAILURE TO OBSERVE CORRECT TIME LACK AWARENESS OF ADVERSE EFFECTS. • • • HARD TO READ HANDWRITTEN ORDERS DIFFERENT DRUGS DRUG ALLERGIES
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Sentinel event

  • 1. SENTINEL EVENTS 1. 2. 3. 4. 5. 6. 12040141014 DEEVYA GAIKWAD 12040141017 AFSHEEN IRANI 12040141019 KIRAN KAUSHIK DASH 12040141020 KIRTI CHOUKIKAR 12040141021 RASHI THAPER 12040141022 STUTI SANGADA
  • 2. SENTINEL EVENTS  A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.  Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures.  The Joint Commission tracks events in a database to ensure events are adequately analysed and undesirable trends or decreases in performance are caught early and mitigated.
  • 3. Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof" and all of the following, even if the outcome was not death or major permanent loss of function:  Infant abduction, or discharge to the wrong family.  Unexpected death of a full-term infant.  Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).  Surgery on the wrong individual or wrong body part.  Instrument or object left in a patient after surgery or another procedure.  Rape in a continuous care setting.  Suicide in a continuous care setting, or within 72 hours of discharge.  Hemolytic transfusion reaction due to blood group incompatibilities.  Radiation therapy to the wrong body region or 25% above the planned dose.
  • 4. Event types- NABH  Surgical events ( wrong body part/ patient/ procedure, retained instrument, death during the procedure, anesthesia related events)  Device or Product events (contaminated drugs and device, unintended use, breakdown or failure)  Patient protection events (infant discharge, elopement, suicide, attempted suicide, self-harm, intentional injury, nosocomial infection, medical gas )  Environmental events ( burn, slip, trip, fall, electric shock, use of restrains and bed rails)  Care management events (hemolytic reaction, maternal death, medication errors, delay in response)  Criminal events (impersonation, abduction, sexual assault, physical assault on the grounds of healthcare facility)
  • 5. DIFFERENCE BETWEEN MEDICAL ERROR & SENTINEL EVENT MEDICAL ERROR  44,000 AND 98,000 AMERICANS DIE EACH YEAR  COMMON MEDICAL ERRORS  INCORRECT ADMINISTRATION OF • • MEDICATION  DOSAGE OR ROUTE OF ADMINISTRATION  FAILURE TO PRESCRIBE OR ADMINISTER CORRECT DRUG  USE OF OUTDATED DRUGS  FAILURE TO OBSERVE CORRECT TIME  LACK AWARENESS OF ADVERSE EFFECTS.  HARD TO READ HANDWRITTEN ORDERS  DIFFERENT DRUGS  DRUG ALLERGIES • SENTINEL EVENT: DEATH PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK • • • • • • • LOSS OF LIMB OR FUNCTION SUICIDE RAPE INFANT DEATH INFANT DISCHARGED TO WRONG PARENTS SURGERY ON WRONG PATIENT, OR BODY PART INCORRECTLY MATCHED BLOOD TRANSFUSION 1,900 SENTINEL EVENTS REVIEWED BY THE JOINT COMMISSION SINCE JANUARY 1995 • • • • PATIENT SUICIDE ACCOUNTED FOR 16.5% OF THE ERRORS OPERATIVE/POST-OPERATIVE COMPLICATION – 12.3% WRONG-SITE SURGERY – 11.7 MEDICATION ERROR – 11.5
  • 6. SENTINEL EVENT POLICY To have a positive impact in improving patient care, treatment, and services and preventing sentinel events. To focus the attention of a disease-specific care program that has experienced a sentinel event. Understanding contributed factors to an event (such as underlying causes, latent conditions, and active failures in defense systems or organizational cultures). Disease-specific care program’s systems, culture, and processes to reduce the probability of such an event in the future. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention. To maintain the confidence of the public and certified programs in the certification process.
  • 7. EXPECTATIONS FOR ORGANIZATIONS REPORTING: ROOT CAUSE ANALYSIS • PROCESS TO IDENTIFY BASIC OR CAUSAL FACTORS OF SENTINEL EVENTS CURRENT OR IN FUTURE ACTION PLAN • PLAN TO IDENTIFY STRATEGIES TO IMPLEMENT REDUCED RISK OF SENTINEL EVENTS SURVEY PROCESS • EVALUATE THE FACILITIES COMPLIANCE WITH APPLICABLE STANDARDS • SCORE PERFORMANCE
  • 8. Sentinel Event is Identified: Inform the CEO Sentinel event identified Reported to the Joint Commissio n Review Process for responding to Sentinel event Interview Leaders Root Cause Analysis
  • 9. • IN SUMMARY • • SENTINEL EVENT: • UNEXPECTED • • DEATH • • LOSS OF LIMB OR FUNCTION SUICIDE RAPE INFANT DEATH INFANT DISCHARGED TO WRONG PARENTS SURGERY ON WRONG PATIENT, OR BODY PART INCORRECTLY MATCHED BLOOD TRANSFUSION POLICY: • IMPROVING • • • • • • PATIENT CARE TREATMENT SERVICES PREVENTING SENTINEL EVENTS FOCUS ON DISEASE SPECIFIC CARE INCREASE KNOWLEDGE CLASSIFY AND RESPOND TO SENTINEL EVENT • • • PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK • • • • • • REPORTING: • ROOT CAUSE ANALYSIS ACTION PLAN IMPLEMENT IMPROVEMENTS MEDICAL ERROR • INCORRECT ADMINISTRATION OF MEDICATION • • • • • DOSAGE OR ROUTE OF ADMINISTRATION FAILURE TO PRESCRIBE OR ADMINISTER CORRECT DRUG USE OF OUTDATED DRUGS FAILURE TO OBSERVE CORRECT TIME LACK AWARENESS OF ADVERSE EFFECTS. • • • HARD TO READ HANDWRITTEN ORDERS DIFFERENT DRUGS DRUG ALLERGIES