What is a sentinel event?

[Jaellys]

A meeting for a sentinel event?

[canoehead, BSN, RN]

What does RCA stand for?

[Penelope_Pitstop, BSN, RN]

canoehead said:

What does RCA stand for?

Root Cause Analysis

[Davey Do]

A Sentinel Event is defined by The Joint Commission as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness.

[Davey Do]

canoehead said:

What does RCA stand for?

It also stands for Radio Corporation of America where Elvis recorded, in the New York studios using a stairwell, "Heartbreak Hotel" on January 10, 1956.

(Just a little useless trivia.)

[Wlaurie, RN]

My understanding is that a sentinel event is something that happens that is life altering such as a massive stroke, MI or such.

[K+MgSO4, BSN]

Wlaurie said:

My understanding is that a sentinel event is something that happens that is life altering such as a massive stroke, MI or such.

Not exactly. A sentinal event is one that is extremely unexpected such as a 30y/o stroking on a gastroscope, while one of the risks of any procedure it is a lot less likely than in a 90y/o with a hip fracture.

A sentinal event is sometimes referred to as a "never event"

Wrong site surgery resulting in death or major, permanent loss of function

Retained instrument or other material requiring further surgery

ABO incompatibility reaction

Intravascular gas embolisom causing death or neurological damage

Medication error leading to death of the patient reasonably believed to be due to the med error

Maternal death associated with pregnancy birth and the puerperium

Suicide of a pt in a mental health unit

Infant discharged to the wrong family

An RCA or root cause analysis is an investigation into the factors that caused the incident. It is performed by a number of experts, those involved are interviewed but not on the investigation panal. A similar specialist will be engaged e.g. if it was a retained instrument in a general colorectal surgery then a surgeon of hepatobillary surgery may be on the panal. This gives an expectation of what would normally happen.

The results of an RCA have to be reported to the relevant authorities.

Other serious investigations may also occur e.g. fall with fracture of a patient, development of an unstageable pressure injury, if there has been a trend of near misses in an area a review of processes may occur. These may not have to be reported to the relevant authorities but would be tabled to the board.

[Here.I.Stand, BSN, RN]

Or an elder with dementia eloping from her memory care home and dying of hypothermia... true story.

RCA.... or observation, not sure ... showed door alarm did not sound when she left. It wasn't staff's fault at all

[K+MgSO4, BSN]

Here.I.Stand said:

Or an elder with dementia eloping from her memory care home and dying of hypothermia... true story.

RCA.... or observation, not sure ... showed door alarm did not sound when she left. It wasn't staff's fault at all

RCA would show that it was maintenance staff fault. All RCA should look outside of 1 craft group i.e. Swiss cheese model of errors.

[Here.I.Stand, BSN, RN]

K+MgSO4 said:

RCA would show that it was maintenance staff fault. All RCA should look outside of 1 craft group i.e. Swiss cheese model of errors.

Good point... when I said "staff" I was thinking of the direct care staff.

[Oldmahubbard]

An 85 y/o man in a Western NY LTC facility was able to get out of the window is his room. Apparently he was desperate to escape, and was using his sheets as a rope, but the sheets did not hold and he fell 5 stories to his death.

[Buckeye.nurse]

Many (think hundreds) of potentially serious or life threatening medication errors occur at hospitals across the country yearly. They are often related to IV pump programming. Most of us would question giving 100 pills...and would call the pharmacist! However, accidentally programming in a 0 instead of a decimal point is not outside the realm of possibility, and results in an insulin gtt dose of 205 units/hr instead of 2.5 units/hr. Many situations just like this have been reported to the Joint Commission as sentinel events. Root cause analysis has resulted in best practice advisories such as independent double checks, smart pumps with guard rails, and pumps that program themselves from the computer MAR. Here are a few articles that go into more depth. (Hopefully they link correctly!)

camh_2012_update2_24_sepdf.pdf

SEA_11pdf.pdf