What Is a Sentinel Event in Healthcare? 5 Prevention Steps for Facilities

Last Updated on March 12, 2024

What Is a Sentinel Event in Healthcare? | CareerStaff Unlimited

Of the many challenges to achieving the highest level of care, sentinel events are among the most threatening. For healthcare organizations and employers, sentinel events represent not just a serious risk to outcomes, but also community standing and financial health. But what is a sentinel event in healthcare, exactly? What makes them important, and what can leaders do to avoid them?

To answer these urgent questions, discover the insights and explore five sentinel event management and prevention steps that every healthcare leader should know in today’s landscape.

What is a Sentinel Event in Healthcare?

So, what is a sentinel event in healthcare, and why is it a matter of concern for leaders? According to The Joint Commission, a sentinel event is a “patient safety event that results in death, permanent harm, or severe temporary harm,” and which aren’t related to the “natural course of the patient’s illness or underlying condition.”

Examples of Sentinel Events in Healthcare

Harmful to providers as well as patients, these events are described as “sentinel” because of the need “for immediate investigation and response.” And the list includes a wide variety of negative incidents, including:

  • Patient falls, both with and without staff present, that directly result in death, bone fracture, or the need for surgery, casting, traction, extra consultation or management, or other treatments
  • Patient suicide, either while in the facility or within 72 hours of discharge
  • Unanticipated infant death, or discharge to wrong family
  • Severe neonatal hyperbilirubinemia
  • Intrapartum maternal death or morbidity (causing severe or permanent harm)
  • Homicide of any patient or staff member, either on-site or while involved in care
  • Physical or sexual abuse or assault of any patient, staff member, visitor or vendor, either on-site or while involved in care
  • Patient abduction or unauthorized departure that leads to death or severe harm
  • Errors in surgery (wrong site, patient, or procedure, or retention of a foreign object)
  • Errors in blood or blood product administration
  • Errors in fluoroscopy leading to permanent tissue injury
  • Errors in radiotherapy (wrong patient, body region, procedure or dosage)
  • Errors in equipment leading to patient harm from “fire, flame, or unanticipated smoke, heat, or flashes occurring”

How common are sentinel events in healthcare? The Joint Commission received 1,441 reports of such events in 2022 alone, a 19% increase from 2021. The most common by far is patient falls.

On average, 20% of reported sentinel events either result in, or are associated with, the death of a patient. Almost half (44%) result in temporary harm described as severe. And 13% lead to the need for added treatments or procedures, or a longer stay.

How Do Sentinel Events Impact Healthcare Providers?

These consequences are severe not just to patients and providers, but to healthcare facilities and their leaders, too. Obviously, a high rate of sentinel events will damage quality of care. They can also harm an organization’s ability to earn reimbursement, particularly in the era of value-based care. They also impact public reputation and the ability to attract new patients.

As the most prominent healthcare accreditation authority in the United States, The Joint Commission actively works to help facilities prevent sentinel events. Since 1996, its official Sentinel Event Policy provides healthcare employers with the information and guidance to meet this important goal.

And, although 88% of sentinel events occur in hospitals, they can also happen in any facilities that provide care. As a result, The Joint Commission offers guidance for a number of different settings. That includes hospital settings like ambulatory health, behavioral health, critical access, laboratory, and office-based surgery. Assisted living, home care, nursing care are also offered. You can find a list of prevention policies by setting here.

5 Steps for Sentinel Event Management and Prevention

In addition to reviewing and following The Joint Commission’s Sentinel Event Policy guidelines, what else can healthcare leaders do to manage and prevent sentinel events in the facilities they oversee?

#1: Create a Sentinel Event Response System

The first step to managing sentinel events is creating an effective response system. “All healthcare organizations should have a policy for responding to a sentinel event,” write Kamakshya P. Patra, MD and Orlando De Jesus, MD in a 2023 analysis of Joint Commission policies. This can include protocols for:

  • Stabilizing patients
  • Disclosing the event, to both the patient and family
  • Providing support for family and staff
  • Ensuring staff and managers notify hospital leaders
  • Conducting Immediate investigation
  • Conducting a complete systematic review

Conducting a root cause analysis (RCA) to identify the cause and/or contributing factors (including “cultural, latent, and active failures”), and developing strong, actionable plans to correct and prevent them.

#2: Revisit Communication Processes

The next step is to implement organization-wide improvements to address common causes of sentinel events. According to The Joint Commission, sentinel events are most often caused by communication breakdowns. This means failing to establish a “shared understanding or mental model across care team members,” or having a system of “inadequate staff-to-staff communication of critical information.”

#3: Revisit Patient Safety Models

The Joint Commission recommends making updates and improvements to patient safety systems as well as communication. Specifically, organizations that provide care “should have an integrated approach” to ensure the highest level of safety “for every patient in every care setting and service.”

Organizations should also work to share its patient safety efforts with the community. According to the report from Dr. Patra and Dr. De Jesus, that means letting it be known that “patient safety is a topmost priority.”

#4: Create a Culture of Safety

Successfully improving both communication and patient safety models usually requires a change in the culture, too. Leaders can work toward this goal by sharing their findings of sentinel event reports with staff members. They should also encourage active participation from everyone involved — not just workers, but also patients, families, and even visitors.

“Sentinel event prevention is a team sport,” write the authors of a 2023 report on risk management. And that means creating a culture where “anyone, regardless of perceived status or importance, is welcomed to contribute their concerns regarding patient safety,” and by “creating a system in which everyone is empowered to speak up.”

The culture of safety “must be pervasive,” they add, “from the highest hospital administrator to the newest volunteer, patient safety-focused training must begin on day one of the new hire orientation and be reinforced frequently throughout an employee’s career.”

#5: Report Sentinel Events to The Joint Commission

Finally, The Joint Commission “strongly” encourages (but doesn’t require) accredited organizations to self-report events. Doing so will help them better manage and respond to sentinel events to give them:

  • Access to resources and support from the commission during the review of those events
  • The chance to confer with a “patient safety expert in The Joint Commission’s Sentinel Event Unit of the Office of Quality and Patient Safety”
  • A reputation for transparency, which can help boost public confidence
  • The opportunity to promote a “culture of safety” in their organization
  • A means to help prevent future events by adding to the commission’s Sentinel Event Database of preventive knowledge

You can read more about how to comply with The Joint Commission’s sentinel event response recommendations here.

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From nationwide clinical staffing to strategic workforce management services, our Joint Commission-Certified healthcare solutions are available for all types of organizations across the United States. With over 30 years of expertise, we can assist you in tackling today’s healthcare workforce and management challenges. Contact us today to discover more about our solutions.

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