Of the 257 sentinel events reported to the JCAHO 153 occurred in general hospitals, 55 in psychiatric hospitals, 21 on the psych unit, and 12 in the ED. The fourth highest number of sentinel events have occurred in the ED. Also a federal statute has been introduced into Congress to protect the RCA from discovery but this bill has not been passed. Hospitals will soon be given four options to select based on their state's statute (law) and case law.
Several steps are being taken to minimize this risk. Most facilities do not self report to the Joint Commission because of legal concerns that their state peer review statute veil of protection would be pierced and that the report could be discoverable by the plaintiff's attorney in a malpractice case. Reporting of sentinel events remains voluntary. Hospitals and other accredited facilities who do not complete the RCA within this time frame are at risk for being placed on accreditation watch by the Joint Commission. It was mentioned that timely reporting is necessary to risk management or the specified individual so the RCA can be completed within the 45-day requirement. A K-rider has to be prepared in pharmacy or KCL is either in premixed IV bags or prepared by pharmacy. This is why more than half of the hospitals in the country have taken potassium chloride off the shelves. The solution is not to fire the nurse but to put into place a system where this incident does not frequently occur. For example, an ED nurse accidentally administers 40 meq. The focus is on systems and processes and not individual performance. In other words, it looks into things such as what caused the problem, why it occurred, and how it could be prevented. A RCA is a risk management tool or process for identifying the basic or causal factors that result in variation in performance. It is important to timely notify the proper person since the facility only has 45 days to complete what is known as a thorough and credible root cause analysis (RCA). Some require the completion of a report such as an incident, occurrence, or sentinel event form. Some policies require notification of the nursing supervisor or risk management. Most facilities have a policy and procedure that outlines the steps a nurse is to take if a sentinel event policy occurs.
#Sentinel events full
Some of the examples of a sentinel event include: any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error, any suicide of a patient in a setting where there is around-the-clock care, any procedure on the wrong patient, any intrapartum maternal death, a patient fall that results in death or major loss of function as a direct result of the injuries sustained in the fall, and a hemolytic blood transfusion reaction involving major blood group incompatibilities.Įxamples of non-sentinel events are: any "near miss," return of full limb or bodily function to the same level as prior to the adverse event by discharge or two weeks after the initial loss, any sentinel event that has not affected a recipient of care (patient, resident, client), medication errors that do not result in death or major loss of function, unsuccessful suicide attempts, retained foreign bodies without major loss of function, or minor degree of hemolysis with no clinical sequelae.Īn ED nurse should check to see if the facility has a policy and procedure on what to do if a sentinel event occurs. The JCAHO recently published a new list of examples. One of the best ways to understand a sentinel event is to look at examples of what are and are not sentinel events. In other words, it is an unexpected incident. Any emergency department (ED) nurse who works for a JCAHO accredited facility should be aware of the sentinel event standard.Ī sentinel event is an event that has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition.
Q: What constitutes a sentinel event according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?Ī: There are approximately 5200 hospitals in the United States that are accredited by JCAHO. JCAHO's sentinel event policy: What every ED nurse should knowīy Sue Dill Calloway RN, MSN, JD, Director of Risk Management, Ohio Hospital Association, Columbus, OH
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