Sentinel Events (SE)

1 CAMHU pdate1, July 2021SE 1 Shadingindicatesa changeeffectiveJuly 1, 2021,unlessotherwisenotedin the What's (SE)I. SentinelEventsThe JointCommissionadopteda formalSentinelEventPolicyin 1996to help hospitalsthat experienceseriousadverseeventsimprovesaf etyand analysisof patientsafetyevents,as well as strongcorrectiveactionsthat provideeffectiveand sustainedsystemimprovement,is essentialto reducerisk and SentinelEventPolicyexplainshow TheJointCommissionpartnerswith hospitalsthat have experienceda seriouspatientsafetyeventto protectthe patient,improvesystems,and preventfurtherharm.*Severetemporaryharmi s critical,potentiallylife-threateningharm lastingfor a limitedtimewith nopermanentresidual,but requirestransferto a higherlevel of care/monitoringfor a prolongedperiodoftime,transferto a higherlevel of care for a life-threateningcondition,or additionalmajorsurgery,procedure,or treatmentto resolvethe HPI SEC & SSERP atientSafetyMeasurementSystemfor Healthcare,rev.

2 2. ThroopC,StockmeierC. May 16, SentinelEventA sentineleventis a patientsafetyevent(not primarilyrelatedto the naturalcourseofthe patient s illnessor underlyingcondition)that reachesa patientand resultsin any ofthe following:nDeathnPermanentharmnSeveretem poraryharm*An eventis also consideredsentinelif it is one of the following:nSuicideof any patientreceivingcare,treatment,and servicesin a staffedaround-the-clockcare settingor within72 hoursof discharge,includingfromthe hospital semergencydepartment(ED)nUnanticipatedde athof a full-terminfantnDischargeof an infantto the wrongfamilynAbductionof any patientreceivingcare,treatment,and servicesCAMHU pdate1, July 2021SE 2 ComprehensiveAccreditationManualfor HospitalsShadingindicatesa changeeffectiveJuly 1, 2021,unlessotherwisenotedin the What's New.

3 If a clinicaldeterminationwarrantsthe use of Rho(D)positivebloodto a Rho(D)negativerecipientoruncrossmatchedb loodin emergentor lifesavinginterventions,this wouldnot be considereda sentineleventto be reviewed. Administrationof bloodor bloodproductswherethe safety ,potency,or purityhas beencompromisedwhilethe bloodproductin questionwas in the laboratory s :Foodand DrugAdministration,Centerfor BiologicsEvaluationand Sexualabuse/assault(includingrape)as a sentineleventis definedas nonconsensualsexualcontactincludingoral, vaginal,or anal penetrationor fondlingof the individual s sex organ(s)by or moreof the followingmustbe presentto determinethat it is a sentinelevent:nAny staff-witnessedsexualcontactas describedabovenAdmissionby the perpetratorthat sexualcontact,as describedabove,occurredon the premisesnSufficientclinicalevidenceobtai nedby the hospitalto supportallegationsof unconsentedsexualcontactnAny elopement(thatis, unauthorizeddeparture)of a patientfroma staffedaround-the-clockcare setting(includingthe ED),leadingto death,permanentharm,orseveretemporaryhar mto the patientnAdministrationof bloodor bloodproductshavingunintendedABOand non-ABO(Rh, Duffy,Kell,Lewis,and otherclinicallyimportantbloodgroups)

4 Incompati-bilities, hemolytictransfusionreactions,or transfusionsresultingin severetemporaryharm,permanentharm,or death nSexualabuse/assaultof any patientwhilereceivingcare,treatment,and serviceswhileon site at the organization/facilityor whileunderthe supervision/careof theorganization nSexualabuse/assaultof a staff member,licensedindependentpractitioner,v isitor,orvendorwhileon site at the organization/facilityor whileprovidingcare/supervisionto patients/clientsnPhysicalassaultof any patient(leadingto death,permanentharm,or severetemporaryharm)whilereceivingcare,t reatment,and serviceswhileon site at theorganization/facilityor whileunderthe supervision/careof the organizationnPhysicalassault(leadingto death,permanentharm,or severetemporaryharm)of astaff member,licensedindependentpractitioner,v isitor,or vendorwhileon site atthe organization/facilityor whileprovidingcare/supervisionto patients/clientsnHomicideof any patientwhilereceivingcare,treatment,and serviceswhileon siteat the organization/facilityor whileunderthe supervision/careof the organizationnHomicideof a staff member,licensedindependentpractitioner,v isitor,or vendorwhileon site at the organization/facilityor whileprovidingcare/supervisiontopatients /clientsCAMHU pdate1, July 2021SE 3 SentinelEvents Shadingindicatesa changeeffectiveJuly 1, 2021,unlessotherwisenotedin the What's New.

5 ||Surgeriesor otherinvasiveproceduresperformedat the wrongsite, on the wrongpatient,or that arethe wrong(unintended)procedurefor a patientare reviewableunderthe policy ,regardlessof the typeof procedureor the magnitudeof the definedas a procedurein whichskin or mucousmembranesand/orconnectivetissueare incisedor punctured,an instrumentisintroducedthrougha naturalbodyorifice,or foreignmaterialis insertedinto the bodyfor invasiveproceduresincludecentralline and chesttubeinsertions,biopsiesand excisions,and all percutaneousprocedures( ,cardiac,electrophysiology,interventiona lradiology).Exclusionsincludevenipunctur e,whichis definedas a collectionof bloodfroma :Note:Theseexclusionsare still consideredpatientsafetyeventsand shouldbe reviewedby theappropriatelocal qualityand safetyteams.

6 # Aftersurgery is definedas any time after the completionof final skin closure,evenif the patientisstill in the proceduralarea or in the basedon thepremisethat a failureto identifyand correctan unintendedretentionof a foreignobjectpriorto thatpointin the procedurerepresentsa systemfailure,whichrequiresanalysisand also placesthe patientat additionalrisk by extendingthe surgicalprocedureand a foreignobject(for example,a needletip or screw)is left in the patientbecauseof a clinicaldeterminationthat the relativerisk to the patientof searchingfor and removingthe objectexceedsthebenefitof removal,this wouldnot be considereda sentineleventto be ,in suchcases,the organizationshall (1) discloseto the patientthe unintendedretention,and (2) keepa recordof the retentionsto identifytrendsand patterns(for example,by type of procedure,by type of retaineditem,by manufacturer,by practitioner)that may identifyopportunitiesfor improvement.

7 **Fireis definedas a rapidoxidationprocess,whichis a chemicalreactionresultingin the evolutionoflightand heat in :NationalFire :StandardClassificationsfor IncidentReportingand Fire ProtectionData. Quincy,MA:NFPA, otherinvasiveprocedureperformedat the wrongsite, on the wrongpatient,or that is the wrong(unintended)procedurefor a patient||nUnintendedretentionof a foreignobjectin a patientafter an invasiveprocedure,includingsurgery#nSeve reneonatalhyperbilirubinemia(bilirubin>3 0 milligrams/deciliter)nProlongedfluorosco pywith cumulativedose >1,500rads to a singlefield or anydeliveryof radiotherapyto the wrongbodyregionor >25%abovethe plannedradiotherapydosenFire,flame,or unanticipatedsmoke,heat,or flashesoccurringduringdirectpatientcare causedby equipmentoperatedand used by the be consideredasentinelevent,equipmentmustbe in use at the time of the event;staff do not needto be present.

8 **nAny intrapartum(relatedto the birthprocess)maternaldeathCAMHU pdate1, July 2021SE 4 ComprehensiveAccreditationManualfor HospitalsShadingindicatesa changeeffectiveJuly 1, 2021,unlessotherwisenotedin the What's New. Severematernalmorbidityis defined,by the AmericanCollegeof Obstetricsand Gynecology,the USCentersfor DiseaseControland Prevention,and the Societyof Maternal-FetalMedicine,as a patientsafetyeventthat occursfromthe intrapartumthroughthe immediatepostpartumperiod(24 hours),requiringthe transfusionof 4 or moreunitsof packedred bloodcells (PRBC)and/oradmissionto theintensivecare unit (ICU).Admissionto the ICUis definedas admissionto a unit that provides24-hourmedicalsupervisionand is able to providemechanicalventilationor betteridentifypatientsat risk and timelyimplementationof clinicalinterventionsconsistentwith evidence-basedguidelinesare importantstepsin the ongoingprovisionofsafe and be informedby identifyingoccurrencesofmaternalmorbidit y,reviewingthe cases,and analyzingthe findings.

9 This definitionappliesto all staffed-around-the-clockcare care settingsnot staffedaroundthe clock,the fall mustoccurduringa timewhenstaff are presentin the settingfor thedefinitionto (not primarilyrelatedto the naturalcourseof thepatient s illnessor underlyingcondition)whenit reachesa patientand resultsinpermanentharmor severetemporaryharm nFall resultingin any of the following:any fracture;surgery,casting,or traction;requiredconsult/managementor comfortcare for a neurological( ,skullfracture,subduralor intracranialhemorrhage)or internal( ,rib fracture,smallliverlaceration)injury;a patientwith coagulopathywho receivesbloodproductsas aresultof the fall; or deathor permanentharmas a resultof injuriessustainedfromthe fall (not fromphysiologiceventscausingthe fall) TheThe aboveabovelistlist isis consistentconsistentacrossacrossallall JointJointCommissionCommissionaccreditat ionaccreditationprograms,programs,though thoughsomesomeofof thesetheseeventseventsmaymay bebe unlikelyunlikelytoto occuroccurinin casesinwhichthe hospitalis uncertainthat a patientsafetyeventis a sentineleventas definedbyThe JointCommission,the eventwill be presumedto be a patientsafetyeventand not asentineleventunlessdeterminedotherwiset hroughfurtherinvestigationor thepresentationof shouldbesharedwith the Officeof Qualityand PatientSafetythroughan organizationresponse(seethe PatientSafetySystems [PS] chapter).

10 AllAll sentinelsentineleventseventsmustmustbebe reviewedreviewedbyby thethe hospitalhospitalandand areare subjectsubjecttoto reviewreviewbyby expectedto identifyand respondappropri-atelyto all sentinelevents(as definedby The JointCommission)occurringin thehospitalor associatedwith servicesthat the appropriateresponseincludesall of the following:nA formalizedteamresponsethat stabilizesthe patient,disclosesthe eventto thepatientand family,and providessupportfor the familyas well as staff involvedinthe eventCAMHU pdate1, July 2021SE 5 SentinelEvents Shadingindicatesa changeeffectiveJuly 1, 2021,unlessotherwisenotedin the What's hospitalleadershipnImmediateinvestigatio nnCompletionof a comprehensivesystematicanalysisfor identifyingthe causalandcontributoryfactorsnStrongcorre ctiveactionsderivedfromthe identifiedcausaland contributingfactorsthat eliminateor controlsystemhazardsor vulnerabilitiesand resultin sustainableimprovementover timenTimeline for implementationof correctiveactionsnSystemicimprovementwit h measurableoutcomesSentineleventsare one categoryof an event,incident.