SENTINEL EVENTS1. 12040141014 DEEVYA GAIKWAD

2. 12040141017 AFSHEEN IRANI

3. 12040141019 KIRAN KAUSHIK DASH

4. 12040141020 KIRTI CHOUKIKAR

5. 12040141021 RASHI THAPER

6. 12040141022 STUTI SANGADA

SENTINEL EVENTS

A Sentinel Event is defined by The Joint Commission (TJC) 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.

Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures.

The Joint Commission tracks events in a database to ensure events are adequately analysed and undesirable trends or decreases in performance are caught early and mitigated.

Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the

risk thereof" and all of the following, even if the outcome was not death or major

permanent loss of function: Infant abduction, or discharge to the

wrong family. Unexpected death of a full-term infant. Severe neonatal jaundice (bilirubin

over 30 milligrams/deciliter). Surgery on the wrong individual or

wrong body part. Instrument or object left in a patient

after surgery or another procedure. Rape in a continuous care setting. Suicide in a continuous care setting, or

within 72 hours of discharge. Hemolytic transfusion reaction due to

blood group incompatibilities. Radiation therapy to the wrong body

region or 25% above the planned dose.

Event types- NABH Surgical events( wrong body part/ patient/ procedure, retained instrument, death during the procedure, anesthesia related events) Device or Product events(contaminated drugs and device, unintended use, breakdown or failure) Patient protection events(infant discharge, elopement, suicide, attempted suicide, self-harm, intentional injury, nosocomial infection, medical gas ) Environmental events( burn, slip, trip, fall, electric shock, use of restrains and bed rails) Care management events(hemolytic reaction, maternal death, medication errors, delay in response) Criminal events (impersonation, abduction, sexual assault, physical assault on the grounds of healthcare facility)

DIFFERENCE BETWEEN MEDICAL ERROR & SENTINEL EVENTMEDICAL ERROR44,000 AND 98,000 AMERICANS DIE EACH

YEAR

COMMON MEDICAL ERRORS

INCORRECT ADMINISTRATION OF MEDICATION

DOSAGE OR ROUTE OF ADMINISTRATION

FAILURE TO PRESCRIBE OR ADMINISTER CORRECT DRUG

USE OF OUTDATED DRUGS

FAILURE TO OBSERVE CORRECT TIME

LACK AWARENESS OF ADVERSE EFFECTS.

HARD TO READ HANDWRITTEN ORDERS

DIFFERENT DRUGS

DRUG ALLERGIES

SENTINEL EVENT:• DEATH

• PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK

• LOSS OF LIMB OR FUNCTION

• SUICIDE

• RAPE

• INFANT DEATH

• INFANT DISCHARGED TO WRONG PARENTS

• SURGERY ON WRONG PATIENT, OR BODY PART

• INCORRECTLY MATCHED BLOOD TRANSFUSION

• 1,900 SENTINEL EVENTS REVIEWED BY THE JOINT COMMISSION SINCE JANUARY 1995

• PATIENT SUICIDE ACCOUNTED FOR 16.5% OF THE ERRORS

• OPERATIVE/POST-OPERATIVE COMPLICATION – 12.3%

• WRONG-SITE SURGERY – 11.7

• MEDICATION ERROR – 11.5

SENTINEL EVENT POLICYTo have a positive impact in improving patient care, treatment, and services and preventing sentinel events.

To focus the attention of a disease-specific care program that has experienced a sentinel event.

Understanding contributed factors to an event (such as underlying causes, latent conditions, and active failures in defense systems or organizational cultures).

Disease-specific care program’s systems, culture, and processes to reduce the probability of such an event in the future.

To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention.

To maintain the confidence of the public and certified programs in the certification process.

EXPECTATIONS FOR ORGANIZATIONSREPORTING:

ROOT CAUSE ANALYSIS

• PROCESS TO IDENTIFY BASIC OR CAUSAL FACTORS OF SENTINEL EVENTS CURRENT OR IN FUTURE

ACTION PLAN

• PLAN TO IDENTIFY STRATEGIES TO IMPLEMENT REDUCED RISK OF SENTINEL EVENTS

SURVEY PROCESS

• EVALUATE THE FACILITIES COMPLIANCE WITH APPLICABLE STANDARDS

• SCORE PERFORMANCE

Inform the CEO

Sentinel event

identified

Reported to the

Joint Commiss

ion

Review Process

for respondi

ng to Sentinel

event

Interview

Leaders

Root Cause

Analysis

Sentinel Event is Identified:

IN SUMMARY• SENTINEL EVENT:

• UNEXPECTED

• DEATH

• PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK

• LOSS OF LIMB OR FUNCTION

• SUICIDE

• RAPE

• INFANT DEATH

• INFANT DISCHARGED TO WRONG PARENTS

• SURGERY ON WRONG PATIENT, OR BODY PART

• INCORRECTLY MATCHED BLOOD TRANSFUSION

• POLICY:

• IMPROVING

• PATIENT CARE

• TREATMENT

• SERVICES

• PREVENTING SENTINEL EVENTS

• FOCUS ON DISEASE SPECIFIC CARE

• INCREASE KNOWLEDGE

• REPORTING:

• CLASSIFY AND RESPOND TO SENTINEL EVENT

• ROOT CAUSE ANALYSIS

• ACTION PLAN

• IMPLEMENT IMPROVEMENTS

• MEDICAL ERROR

• INCORRECT ADMINISTRATION OF MEDICATION

• DOSAGE OR ROUTE OF ADMINISTRATION

• FAILURE TO PRESCRIBE OR ADMINISTER CORRECT DRUG

• USE OF OUTDATED DRUGS

• FAILURE TO OBSERVE CORRECT TIME

• LACK AWARENESS OF ADVERSE EFFECTS.

• HARD TO READ HANDWRITTEN ORDERS

• DIFFERENT DRUGS

• DRUG ALLERGIES