Sentinel Event

What is Sentinel Event?

A sentinel event is defined by JCI as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient , not related to the natural course of the patient's illness and not present at the time of services were sought or begun.

A relatively infrequent, unexpected incidence, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of health care services.

 

The 10 most common sentinel events:

1. Unintended retention of foreign object events

2. Fall-related events

3. Suicide events

4. Wrong patient, wrong site, wrong procedure events

5. Delay in treatment events

6. Criminal events (assault, rape, homicide)

7. Operation/post-operation complication events

8. Perinatal events

9. Medication error events

10. Fire-related events

 

Sentinel event includes-

A. *SURGICAL EVENTS*

· Surgery performed on the wrong body part.

· Surgery performed on the wrong patient.

· Wrong surgical procedure performed on the wrong patient.

· Retained instruments in patient discovered after surgery/procedure.

· Patient death during or immediately post surgical procedure.

· Anesthesia related event.

B. *DEVICE OR PROCEDURE EVENTS*

Patient death or serious disability associated with:-

· The use of contaminated drugs, devices, products supplied by the organization.

· The use or function of a device in a manner other than the device’s intended use.

· The failure or breakdown of a device or medical equipment.

· Intravascular air embolism.

C. *PATIENT PROTECTION EVENTS*

· Discharge of an infant to the wrong person.

· Patient death or serious disability associated with elopement from health care facility.

· Patient suicide, attempted suicide, or deliberate self-harm resulting in serious disability.

· Intentional injury to a patient by a staff member, another patient, visitor, others.

· Any incident in which a line designated for oxygen contains the wrong gas or is contaminated by toxic substances.

· Nosocomial infection or disease causing patient death or serious disability.

D. *CRIMINAL EVENTS*

· Any instance of care ordered by or provided by an individual

· Impersonating a clinical member of staff.

· Abduction of a patient.

· Sexual assault on a patient within or on the grounds of the health care facilities.

· Death or significant injury of a patient or staff member resulting from a physical assault or other crime that occurs within or on the ground of the health care facility.

NOTE: ANY SENTINEL EVENT MUST BE REPORTED IN THE INCIDENT REPORTING FORM.

All sentinel events shall analysed within 24 workings hours of occurrences or reporting. The analysis of sentinel events shall be complete within seven days of occurrences or reporting.

Root cause analysis of all such events should be carried out by multi-disciplinary committee taking inputs from the units/discipline/departments concerned.

The findings and recommendations arrived at after the analysis should be communicate to all personnel concerned to improve the system.

 

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