Supporting Safer Healthcare

Bad things happen to good patients, and good caregivers for that matter.  The complex arena of medicine offers many opportunities for systems and processes to go awry, and at times they do just that.  When serious injury, or even significant risk of serious injury is the end result, the event is generally identified as Sentinel.

The Joint Commission defines Sentinel Event as:

“An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called “sentinel” because they signal the need for immediate investigation and response.”

The Joint Commission web site provides statistics, including a table of Sentinel Events reviewed by the organization since 1995. (See image below.)  The numbers are relatively low, however, it is important to note that reporting SE’s to the Joint Commission is voluntary, and most hospitals and providers choose not to self-report the majority of events.**  That having been said, the JC does require all accredited hospitals to establish a process for identifying and investigating events that meet the definition of Sentinel, and also requires that a root cause analysis and action plan for preventing recurrence be developed within 45 days.

Not surprisingly, the individuals charged with the initial investigation and designation of significant events in the healthcare setting often struggle with whether or not a particular event meets the definition of Sentinel.  For example, serious physical or psychological injury may be difficult to determine early in an investigation.  A injury that appears permanent may resolve over time, and one that initially seems minor may worsen.  However, if identification is not made promptly investigation becomes more difficult.  Interviewing caregivers days or weeks after an event occurs will almost certainly diminish the number of accurate details that can be recalled. 

It also becomes far more challenging to develop meaningful action plans after time has passed.  Initially those involved in a difficult case are usually emotionally engaged and anxious to determine what happened and prevent it from happening again.  However, teams called together weeks or months after an event have often lost their emotional engagement and have, perhaps by necessity, put the incident behind them. They may in fact be actively resistant to dredging up old memories.  Obviously, time is of the essence.

Hospital leadership must take an active role in monitoring and supporting the investigation, root cause analysis, and action planning for serious events.  Performed well, the process is a significant driver toward improved patient safety, patient satisfaction, risk mitigation, and protection of the organization’s financial assets.  It also provides the organization an opportunity to offer support to staff members who may be highly distressed over participation in care that did not result in the desired outcome.

John G. Marsh from HealthCare Voice adds this thought in his post A Culture of Hiding Mistakes? “It is important for the CEO – the leader – to own the results, to make quality care and patient safety more than a program or an initiative but a way of EVERY day life in their health system, hospital, nursing home, or healthcare delivery venue.”

Additional Reading:  Don’t Hide Your Mistakes from HealthLeaders Media

How Root Cause Analysis Can Improve Patient Safety from Kevin MD

Joint Commission has reviewed the following Sentinel Events since 1995:**