"What is a sentinel event?"

[prn nurse]

What qualifies an action as a sentinel event?

[kaycee]

I believe it is any action that leads to grave harm or death to a patient, as defined by JCAHO.

[NRSKarenRN, BSN, RN]

from jcaho:

http://www.jcaho.org/ptsafety_frm.html

sentinel event policy

jcaho's sentinel event policy, implemented in 1996, is designed to help health care organizations to identify sentinel events and take action to prevent their recurrence. 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.

any time a sentinel event occurs, the health care organization is expected to complete a thorough and credible root cause analysis, implement improvements to reduce risk, and monitor the effectiveness of those improvements. the root cause analysis is expected to drill down to underlying organization systems and processes that can be altered to reduce the likelihood of error in the future and to protect patients from harm when error does occur. the sentinel event policy also encourages organizations to report to jcaho sentinel events that have resulted in death or serious injury along with their root causes and related preventive actions, so that jcaho can learn about the underlying causes of the sentinel events, share "lessons learned" with other health care organizations, and reduce the risk of future sentinel event occurrences. for questions about the sentinel event policy, organizations can call jcaho's sentinel event hotline, [phone].

sentinel event alert

sentinel event alert is a monthly newsletter that identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future. information for sentinel event alert comes from many sources, including experts, organizations, and jcaho's sentinel event database. the database includes the reported sentinel events, the root causes of these events, and strategies that health care organizations have used to reduce risk to patients. in order to share the most important "lessons learned" from its database and provide important information relating to the occurrence and management of sentinel events in health care organizations, jcaho began publishing sentinel event alert in 1998.

sentinel event alert has raised awareness in the health care community and the federal government about the occurrence of adverse events and ways that these events can be prevented in the future. past issues are available on jcaho's web site, http://www.jcaho.org. topics have included medication errors, wrong-site surgery, restraint-related deaths, blood transfusion errors, inpatient suicides, infant abductions, fatal falls and operative/post-operative complications. in 2001, surveyors began scoring accredited organizations on how they respond to recommendations made in sentinel event alerts. if the recommendations are applicable to their services, the health care organization is required to implement the recommendations or reasonable alternatives, or provide a reasonable explanation for not implementing relevant changes.

[jshudson1]

To be more specific, examples JCAHO uses include amputating the wrong limb, death by error, rape, things like that. JC requires hospitals to file reports directly to them whenever one of these events occur. Then, they require the hospital to do a full scale quality improvement project to make sure it does not happent again.

[night owl]

Here's a link where you can read up on sentinel events:

http://www.jcaho.com/sentinel/sentevnt_frm.html

[night owl]

Wow, look at all the responses before me...that was quick!