A sentinel event denotes any unanticipated event in a healthcare setting that can result in death or serious physical or psychological injury to a patient, which is unrelated to the natural course of the patients’ illness. These events can be caused by a multitude of different factors, all relating to major mistakes and negligence on the part of the healthcare provider. Because these can get pretty intricate in terms of legality, it’s best when cases surrounding these scenarios are handled by our legal nurse consultants in Michigan. For today’s topic, let’s answer the question— What is a sentinel event?
Sentinel Events And The Joint Commission
It should be known that sentinel events are identified under The Joint Commission (TJC) accreditation policies which help to aid in root cause analysis and assist in development of preventative measures. Despite the fact that sentinel events have been on a downward trend in the last decade or so, they still remain a prevalent risk for hospitals. They can happen anywhere along the healthcare continuum, in any setting, statistics report that 68% of them occur in general hospitals.
The Most Common Sentinel Event
The most commonly occurring sentinel events will include unintended retention of a foreign object, falls, and performing procedures on the wrong patient. Here is what the top 10 sentinel events include:
- Unintended retention of a foreign object events
- Fall-related events
- Suicide events
- Wrong patients, wrong site, or incorrect procedure events
- Delay in treatment events
- Criminal events (i.e., assault, rape, homicide)
- Operation/post-op complication events
- Perinatal events
- Medication error events
- Fire-related events
Back in 2019, the Joint Commission reviewed a total of 844 sentinel events. The majority, or 83% were voluntarily self-reported by an accredited or certified organization. Across the board, experts agree that almost all types of sentinel events are under-reported due to varying circumstances like lack of time, fear of punishment, and confusion about the severity of events that require notification. It’s on hospitals to investigate and report on sentinel events, for the sake of their standard operating procedures and the health of future patients.
Handling A Sentinel Event
If you happen to find yourself with a sentinel event in your hospital, The Joint Commission offers a 5-step process of how to proceed.
- Secure the situation—- First things first, ensure the immediate safety and wellbeing of anyone directly involved, including patients and staff.
- Preserve anything that might be helpful in the analysis process, which includes equipment, medication, and much more. You are able to take photos of the scene of the sentinel event to aid in the downstream analysis.
- Disclose situationally relevant information to the patient or to their designated caregiver ASAP.
- Provide unwavering support for patients, family members, and staff. Sentinel events claim many victims, so a robust support system of services is needed.
- Adhere to The Joint Commission’s reporting and root-cause analysis requirements, which are detailed in the organization’s accreditation manual.
Even though one may feel naturally inclined to want to downplay or keep quiet on the event in question, in the long-term, our legal nurse consultants in Michigan strongly encourage you to rectify the situation directly and with honesty. Voluntary reporting will not only improve operations in the hospital, but it will bring to light similar situations for you and your colleagues.
Additional elements to consider for those trying to mitigate sentinel events include:
- Enhancing communication and technology for reporting & addressing
- Enabling more tools for reducing errors
Handling Sentinel Events With Poise & Rationality: Legal Nurse Consultants in Michigan
If you and your legal team are in need of professional oversight for handling sentinel events, you won’t have to search very far when SPLNC & Associates, LLC is only a phone call away. To see what can be done to aid your legal counsel, contact us today!