Sentinel events

Coe CP. 1998b. Overview of the Joint Commissions Sentinel Event Policy. In Preparing the Pharmacy for a Joint Commission Survey, p. 200. Bethesda, MD ASHP. 

Omission errors, incorrect doses, and prescribing errors were the top three causes of medication errors reported by health systems in 2002. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) tracks sentinel events submitted to it by accredited heathcare facilities. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Table 16.3 lisfs fhe roof causes of medication errors reported by JCAHO-accredited organizations. ... 

The JCAHO has a major focus on patient safety, including medication safety. As facilities report internal sentinel events to JCAHO, they are reviewed and analyzed. JCAHO has issued a number of sentinel event alerts, notifying healfh care organizafions and consumers to specific safety issues and practice recommendations to improve them. Several have addressed medication issues such as potassium chloride and other concentrated electrolytes, insulin, heparin, injectable opiates and narcotics, infusion pumps, and look- and sound-alike medications and abbreviations. Table 16.10 summarizes the recommendations for these sentinel event alerts. ... 

Table 6.10 Medication-Related JCAHO Sentinel Event Alerts...

JCAHO Sentinel Event Alert No. 1 Medication error prevention — potassium chloride, February 27, 1998. Available at www.jcaho.org, accessed August 5, 2002. 

JCAHO Sentinel Event Alert No. 11 High-alert medications and patient safety, November 19, 1999. Available at www.jcaho.org, accessed August 5, 2002. JCAHO Sentinel Event Alert No. 15 Infusion pumps — preventing future adverse events, November 3, 2000. Available at www.jcaho.org, accessed August 5, 2002. 

Sentinel event reporting and patient safety goals.385... 

The sentinel event reports submitted to the JCAHO are reviewed and cataloged for error type and underlying causes. Medication errors are one of the most common types of sentinel events reported to the JCAHO. When a trend of similar errors is identified, the JCAHO issues a sentinel event alert, which alerts others of the risk and recommends actions to minimize risk in organizations. The first alert issued in 1998 focused on deaths due to the inadvertent IV push administrahon of IV potassium chloride (KCl). Awareness of these events and actions by pharmacists to remove concentrated KCl from patient unit floor stocks has markedly reduced reports of this type of error. Of the 27 subsequent alerts issued in January 2003, seven focus on different types of medication errors and prevention strategies. 

Sentinel event policy and procedure, http //www.jcaho.org/accred-... 

High-alert medications and patient safety. Sentinel Event Alert 11 (Nov 19) 1999. 

Medical surveillance also includes monitoring for a single case of new disease caused by a chemical agent that triggers an alarm in an astute clinician. Such cases, called sentinel events, result in further study and analysis to determine a true cause and effect relationship. Historically, numerous chemical agent induced disease processes have been determined through medical surveillance and sentinel event determination. For example, the relationship between vinyl chloride exposure and hepatic angiosarcoma development was determined by astute medical surveillance. 

Colonization with P. aeruginosa is a sentinel event in the course of cystic fibrosis. Chronic infection with this organism is associated with progressive loss of lung function attributed to chronic inflammation and recurrent pulmonary exacerbations. Thus, there is interest in strategies that may delay the acquisition of this organism. 

The two major types of performance measures are 1) rate-based performance measures, which measure an event for which a certain proportion of the events are expected to occur even with quality care (such as mistimed prescription refills) and 2) sentinel-event performance measures, which measure a serious event that requires an indepth review for each occurrence of the event (such as a medication error).To provide meaningful information, performance measures must be... 

The first element in risk assessment is knowledge of the chemical exposures of a workforce to see if a known sensitizer is present. A chemical becomes accepted as a cause of occupational asthma if there are at least two convincing clinical case reports from independent centres. Specialist clinicians are likely to be aware of the published literature at an early stage and may be a useful source of informal information. There is currently much interest in publishing lists of sensitizers. One is available in a recent textbook (Chan-Yeung and Malo, 1993). The Health and Safety Executive in the UK, the National Institute for Occupational Safety and Health in the USA and other agencies may publish lists with updates. Other sources of information on causes are reporting schemes such as SWORD (Surveillance of Work-related and Occupational Respiratory Disease) in the UK (Ross el al., 1995) and SENSOR (Sentinel Event Notification System for Occupational Risks) in some states in the USA (Matte et al., 1990). 

Sentinel event alert. Safely implementing health information and converging technologies. Jt Comm. Dec 2008 11 (42). http //www.jointcommission.Org/assets/l/18/SEA 42.PDE... 

Indicators can also be classified as sentinel-event indicators and aggregate data indicators. A performance measurement of an individual event that triggers further analysis is called a sentinel-event indicator. These are often undesirable events that do not occur often. These are often related to safety issues and do not lend themselves easily to quality-improvement opportunities. An example may include equipment failures that result in a patient injury. 

Define Indicator. The definition of the indicator to be monitored must be carefully developed. This process includes at least five steps. The event or outcome to be measured must be described. Define any specific terms that are used. Categorize the indicator (sentinel event or rate based, process or outcome, desirable, or undesirable). The purpose for this indicator must be defined, as well as how it is used in specifying and assessing the particular process or outcome. 

Establish Threshold. A threshold is a specific data point that identifies the need for the department to respond to the indicator to determine why the threshold was reached. Sentinel-event indicator thresholds are set at zero. Rate indicator thresholds are more complex to define because they may require expert consensus or definition of the department s objectives. Thresholds must be identified, including the process used to set the specific level. 

Lachenbruch PA, Mttes J. 2007. Sentinel event methods for monitoring unanticipated adverse events. In Advances in Statistical Methods for the Health Sciences, J-L Auget, N Balakrishnan, M Mesbah, G Molenberghs (eds.). Birkhauser, Boston, MA, pp. 61-74. 

A Sentinel Event puts Patient Safety in the Spotlight... 

In 2004 the occurrence of a sentinel event - an incompatible blood group heart transplant - at University Hospital Zurich abruptly made patient safety a central concern of the hospital. This sentinel event created a major public stir, not least because the patient, who died in the postoperative period, was followed live by a television reporting team. The way in which this sentinel event was dealt with thus became a matter of public interest. Attention was no longer focused... 

Step 2 Inform all staff personnel whenever a sentinel event is reported. 

Step 6 Identify and separate each event sequence that may have been a contributory factor in the sentinel event occurrence. 

Step 7 Brainstorm about the factors surroimding the selected events that may have been contributory to the sentinel event occurrence. 

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) in the United States recommends that all health care facilities in the country respond to sentinel events by using RCA within 45 days of their occurrence. 

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