Sentinel Events in hospitals

A Sentinel Event is defined by the Joint Commission International (JCI) 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. These are usually the most serious events in hospitals, and include:

Ø  Unexpected death

Ø  Patient suicide

Ø  Wrong patient, wrong side, wrong site surgery

Ø  Infant abduction

Ø  Sexual assault on patient

Ø  Haemolytic blood transfusion reaction resulting from incompatible bllopd transfusion

Ø  Intrapartum maternal death

Ø  Assault, homicide or other crime resulting in permanent loss of function or death

Sentinel events are intensively monitored by the Joint Commission International  ( JCI) and the National Accreditation Board for Hospitals & Healthcare Providers (NABH).Theses events require a Root cause Analysis ( RCA) to detect the underlying causes, and come up with solutions to prevent the recurrence of the event. At the same time, potential measures of improvement, called an “ Action Plan”, are to be implemented.

The Joint Commission disseminates "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence. For hospitals accredited by the JCI, the RCA has to be done within 45 days of the event, and suitable advisory issued accordingly.

Statistics of sentinel events are recorded and published by the FDA's MedWatch program. The JCAHO publishes a great deal of information about sentinel events on their website: www.jcaho.org. They also send out Sentinel Event Alerts that are available to all health care providers and organizations as a means of increasing the general knowledge about sentinel events.

Sentinel events usually point out a system or process defect, rather than a defect related to any one individual. They have to be taken in this context and analyzed thereof.

An example of a Sentinel Event in a hospital:

ROOT CAUSE ANALYSIS
S/ 01/ 11
Type of event	Sentinel event
Event	Inj.Vancomycin given by improper technique ( iv bolus instead of infusion)
What happened?	Patient was scheduled for OMC+ ASD closure.Doctor had prescribed Inj. Vancomycin I gm iv bd without mentioning dilution. Nurse gave the medication as iv bolus after dilution in 20 ml NS, whereas it should have been diluted in 100 ml. Patient developed discolouration of hand- this progressed to thrombophlebitis with left hand pain, burning and blackish discolouration. The operation was cancelled due to this and patient was discharged. At the time of discharge, patient was having discolouration and pain, with flexion problems of the hand. Patient was later readmitted , having suffered deep skin necrosis and underwent debridement and flap cover surgery.
Analysis using the " 5 times why" technique
Why did thrombophlebitis develop?	Due to improper dilution and technique of administration
Why was the improper technique followed?	Since nurse was not aware
	Since doctor had not mentioned it  in medication order
Why was nurse not aware?	Dilution guidelines not available at ward
	Knowledge and training was insufficient
Why had doctor not mentioned in medication order?	Due to oversight
Factors affecting this event ( Ishikawa Diagram) Action and followup 1. The consultant, junior doctor and and nurse were counselled. 2. Nursing managers were instructed to oversee Medication process including indenting and administration, in every shift.     They would be responsible for this process. 3.List of high risk medication prepared by Clinical Pharmacy- to be provided at the Nursing Stations 4. Label of high risk drug is to be provided on each vial of identified drugs. 5. List of drugs requiring dilution is also being prepared by Clinical Pharmacy. This would mention the diluent, dilution factor and     infusion rate. 6. Training of nurses on Medication Management Suggestions 1. Medication management module can be introduced during the induction of doctors and nurses. 2. Regular medication management classes for doctors and nurses 3. The drug company should be communicated with, to provide proper risk identification labelling for Vancomycin, and to mention the dilution factor 4. Identification of high-risk medications to distinguish easily visually Follow-up 1. Medication management classes conducted 2. High risk medication chart and labelling of high risk medications introduced 3. Doctors and nurses are given information on medication management during induction