Sentinel Events

The Joint Commission is a not-for-profit national organization that accredits more than 19,000 health care institutions in the United States.  Their mission is

“To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” (Joint Commission, 2011)

Joint Commission accreditation is an indication that the organization that gets accredited by The Joint Commission (TJC) is committed to high quality health care and proves it by meeting performance standards.

The Joint Commission accredits all areas where nurses practice: ambulatory care, acute and long term facilities, hospitals, homecare and behavioral health care.

Learn more about the Joint Commission  at  www.jointcommission.org

The Joint Commission establishes National Patient Safety Goals (NPSG) for each of the areas they accredit. To read more about NPSG  click here.

As part of their mission TJC reviews and follows up on an institution’s sentinel event. A sentinel event as defined by TJC is “an unexpected occurrence involving death or a serious physical or psychological injury or the risk thereof.” In other words a sentinel event is when something really bad happens that could have been avoided.

Some examples of sentinel events are; suicide of a patient within the institution. an infant abduction from the institution, a hemolytic blood transfusion reaction, wrong site surgery or some cases of aspiration pneumonia.

When a sentinel event occurs the institution is required to submit a Root Cause Analysis (RCA) and action plan to TJC within 45 days of the event or the discovery of the event.

A RCA looks at the reasons for the failure or inefficiency of the processes that contributed to the event. It DOES NOT look at individuals, but on the policies and procedures in place to see if they could be improved in order to prevent this event from happening in the future. The action plan is the strategies an organization will put into place to ensure this sentinel event is not repeated.

Many nurses who orient to a new job or as a new graduate are exposed to reams of paper work on a variety of subjects that are boring and inundating. Their thoughts are “Just let me take care of patients!” Unfortunately, the organization will make you sign a document stating you received all of the paper work and that you are responsible for all of the information contained in it. Many nurses sign this without a second thought, throw the paper work away and continue to go on with “taking care of patients.” There is no need to think about it again until something happens and you are involved in a sentinel event.  You state, “I never knew I had to do that.” And the organizations risk management department will say, “You were told that information at orientation and we have a signed document that proves it.”

I am not trying to scare you but the medical environment is also a legal environment and you ARE responsible for knowing your institution’s policies and procedures.

To this end, I will be discussing some examples of sentinel events and how you as a nurse can protect yourself from litigation from them.

In my next post I will be discussing a topic that is frequently seen in nursing practice, is not emphasized in nursing school and in which a theory to practice gap exists; how to check placement of an NG tube. Stay tuned.