After last week’s news about Tareq and Michaele Salahi’s White House adventures I began to consider whether, if one were applying healthcare criteria, the event would be classified as Sentinel or Near Miss.
Some unanticipated healthcare outcomes are clearly Sentinel (an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, per the Joint Commission). Many times however, there is room for educated discussion as to whether an event should be classified as Sentinel or Near Miss.
For a hospital the difference in classification can impact the course of action and level of leadership involvement that occurs following a particular event. Event classification is usually performed in the Risk Management or Quality Department.
Consider the Salahis.
Since someone who was apparently not entitled to be present in the White House was touching the President, Vice-President and other officials, the matter clearly seems to meet the criteria of “the risk thereof” for death or serious injury. Therefore, I would classify this event as Sentinel.
Some might argue that because the Salahis, along with other guests, were screened for weapons prior to entry, a Near Miss classification would be sufficient. I would agree had the Salahis made it through some levels of screening, but been “discovered” and stopped prior to final access to the state dinner.
For example, unplanned retention of a foreign body (we’ll say a sponge) after surgery is a Sentinel Event. If however, before the site is closed and the patient leaves the OR, the count is reported as incorrect and the sponge is discovered through x-ray or re-inspection, the event becomes a Near Miss. Initial screening methods (earlier count or surgical site inspection for example) may not have revealed the presence of a foreign body, but later screening methods did. The patient did not enter the recovery area with a retained foreign body, therefore, the event is a Near Miss.
The White House and Secret Service appear to be treating the presence of uninvited guests at a state dinner as a Sentinel Event. There are no doubt various flow diagrams and root-cause analysis documents being reviewed by high-level leaders in order to assure this type of issue does not reoccur. Healthcare must be as diligent.