A Sentinel Event........

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.

Thanks, nurse!

greenfiremajick · 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.

Thanks for the different spin on it, merlee. And TY for the support.

greenfiremajick · 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.

Thanks, Muno. I appreciate the support.

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.

Your proposal that lack of training could be a catalyst or cause for sentinel events, sounds like a great intro to the way in which systems make things work and why sometimes, they don't. There's lots of training offered all the time, so could it be lack of motivation, as opposed to training? I saw somewhere on AN, a new program for monitoring handwashing, etc...People were complaining about how they feel overly watched and babysat, but I wonder what other options there are for the org, if staff are not adhering to policy?? Lots of things to consider....

mama_d, BSN, RN · Feb 9, 2011

The "lack of training" can come in different ways...lack of an employee in keeping up credentials they should have, a lack of training supplied by the employer, or a lack of the facility to keep up on current evidence based practice.

An example of the latter is the use of rapid response teams...I can remember when they weren't standard although there was plenty of evidence that they helped to prevent codes. One that is another issue IMO is that there have been studies done that indicate that poor patient outcomes can be attributed to poor staffing levels (duh!) but facilities staff as poorly as they can and still get away with.

All the RCAs that I'm aware of that our unit was involved in occurred during shifts that we were short staffed. But the staffing grid hasn't changed. Go figure.