A Sentinel Event........

nurse2033, MSN, RN · Feb 9, 2011

I know it includes a patient death, but I think also covers permanent disability. A root cause is to identify all factors involved, usually multiple.

merlee · Feb 9, 2011

A 'sentinel' event is one that makes everyone stop and take another look. It does not need to be a death. It's the event that causes policies to change, or people to pause and re-examine the way something is being done.

MunoRN, RN · Feb 9, 2011

JCAHO defines a sentinel event as any unexpected event that causes death or serious injury that was not part of the natural course of their illness. Specific examples include: surgery on the wrong body part, patient suicide, patient rape, blood transfusion with incompatible type, surgical instruments left in the patient, etc.

Sentinel event are limited to JCAHO though, my State DOH also defines sentinel events as stage IV pressure ulcers, infusion of any substance into a misplaced NG/OG tube (regardless of harm), etc.

SweetOldWorld, BSN, RN · Feb 9, 2011

OK, I'm having some technical difficulties beyond my control, in getting ahold of the JCAHO Handbook. I have this assignment and I'm hoping you guys can give me some ideas of what a sentinel event would be, in regards to infection control in a hospital setting....
Also any opinions, guidance, or support (websites, real life experiences, etc) that you could give concerning a root cause analysis of a sentinel event would be most appreciated...

APIC has some good info about infection control-related sentinel events.

http://www.apic.org

mn_nurse · Feb 9, 2011

This might be what you are looking for:

http://www.jointcommission.org/sentinel_event_alert_issue_28_infection_control_related_sentinel_events/

and:

http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/

BTW Jont Commission defines a sentinal Event as;

- A sentinel event is 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 terms “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.

Hope this helps

mama_d, BSN, RN · Feb 9, 2011

Root cause analysis is exactly what it sounds like...analyzing the information to determine what the root cause of the event was. Human error? System breakdown somewhere? Lack of training? Then, after the root cause is determined (often it's a cascade of events), steps are put into place to ensure the same thing doesn't happen again. RCA is not supposed to be about blame, but rather identifying weak links in the chain of care delivery that need to be strengthened.

Zookeeper3 · Feb 9, 2011

If you just googled as I did the joint commission "sentinal events"... it's all layed out there. I'm so not doing the work for yur but it is that simple. You're either not wanting to do the work, or looking to hard into the meaning of thier criteria. What they state, is what it is... try going to their site first. Not a homework board and don't appreciate being one either... their statements are the standard. The discussion of those are another post.

greenfiremajick · Feb 9, 2011

I know it includes a patient death, but I think also covers permanent disability. A root cause is to identify all factors involved, usually multiple.

APIC has some good info about infection control-related sentinel events.
http://www.apic.org

Thanks, I appreciate the site!

greenfiremajick · Feb 9, 2011

Thanks, much! I have been to the JCAHO site, but they wanted me to buy the handbook, while my school won't be able to send it to me, until the 14th! I'm new to the whole JCAHO thing.......I truly appreciate this!

This might be what you are looking for:
http://www.jointcommission.org/sentinel_event_alert_issue_28_infection_control_related_sentinel_events/
and:
http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/
BTW Jont Commission defines a sentinal Event as;
- A sentinel event is 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 terms "sentinel event" and "medical error" are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.
Hope this helps

greenfiremajick · Feb 9, 2011

Root cause analysis is exactly what it sounds like...analyzing the information to determine what the root cause of the event was. Human error? System breakdown somewhere? Lack of training? Then, after the root cause is determined (often it's a cascade of events), steps are put into place to ensure the same thing doesn't happen again. RCA is not supposed to be about blame, but rather identifying weak links in the chain of care delivery that need to be strengthened.

TY for the reply!

greenfiremajick · Feb 9, 2011

If you just googled as I did the joint commission "sentinal events"... it's all layed out there. I'm so not doing the work for yur but it is that simple. You're either not wanting to do the work, or looking to hard into the meaning of thier criteria. What they state, is what it is... try going to their site first. Not a homework board and don't appreciate being one either... their statements are the standard. The discussion of those are another post.

TY for your input.