Nonetheless, the importance of identifying, reviewing, and learning from sentinel events cannot be undersold. Therefore, the true number of sentinel events is difficult to pinpoint, and statistical conclusions cannot be accurately drawn. Though the Joint Commission releases an annual report summarizing the sentinel events reviewed by the committee, they include a caveat that these submissions by accredited institutions are encouraged, but not required. Throughout the years, many academic papers have attempted to quantify or rank medical error as a leading cause of death in the United States. By their estimates, between 44,000 and 98,000 patients die each year from preventable medical errors. Institute of Medicine that brought to light the significant issue of medical errors. How pervasive is this issue? In 1999, a monumental report was released by the U.S. However, what if, to check in to the ED, a front desk employee’s responsibility was to give patients the appropriate, color-coded wristband and to check for any bracelets/bands that a patient may be wearing? Medical errors are likely to happen in this environment, but systems-based safety policies, though loaded with redundancies, can reduce the chances that such a medical error progresses any further. It is clear to see that this was one individual’s medical error in misidentifying a patient’s wristband, resulting in a sentinel event. Mistaking it for a Do Not Resuscitate (DNR) band, she doesn’t call the code. The nurse who just began her shift rushes to the patient’s side and notices a purple wristband. Moments later, the patient stops breathing. It is 7:00 PM on a Friday night, and a shift change has just occurred. He drives himself to the local hospital and awaits care in triage. At one point in the evening, a 65-year-old conference attendee with a significant medical history for hypertension, diabetes, and hyperlipidemia begins to feel crushing, substernal chest pain. Attendees are required to wear a purple wristband for admission to the event. Imagine that a real estate conference is being held in a busy downtown. Many hospitals utilize such systems to manage a hectic emergency department efficiently. A white wristband may signify that there is no real urgency, etc. When given a red wristband, this signifies to a healthcare provider that a patient needs immediate medical care. This process focuses on systemic policy changes, not individual performances, to progress.įor example, consider an emergency room triage system that primarily relies on color-coded wristbands to stratify patients who present with various complaints. Likewise, when medical errors occur, though they may result from an individual’s actions, the appropriate next steps fall on the institution to identify, learn from, and improve on the prevention of such events. The healthcare system is made up of individual players, but its ultimate goals of patient care and safety are accomplished through teamwork. Why Is This Important To Clinical Practice? Risk Management: Clinical and administrative activities undertaken to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors and the risk of loss to the organization itself (The Joint Commission 2017). Also established by the Joint Commission, this multi-step process is crucial to identify and fix systemic problems in patient safety and care. Root Cause Analysis: The process for identifying the basic or causal factor(s) underlying variation in performance. In the context of this article, medical errors may fall under the definition of sentinel events if the error is severe enough. Medical Error: The failure of a planned action to be completed as intended or using a wrong plan to achieve an aim. It is important to note that the Joint Commission requires each accredited organization to establish its own definition for a sentinel event to prevent, review, and respond to these occurrences. These events are typically unrelated to the patient’s illness/underlying condition. Sentinel Event: Defined by the Joint Commission as “a patient safety event that results in death, permanent harm, or severe, temporary harm” (The Joint Commission 2017). The awareness of such error-data by health care providers and administrators would lead to the prevention of errors and the global reduction of their recurrence. Policymakers theorized that the systematic collection of medical-error data could achieve improved patient safety. The fundamental goal of this act was to increase the nation’s overall patient safety by encouraging confidential and voluntary reporting of adverse events that affected patients. Provision of assistance to the states in developing standardized methods for data collection and data collection from state reporting systems for inclusion in the patient safety database.
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