34.) Others see no benefit to themselves or their institutions from reporting. For example, do near misses count? (See “Near Misses,” The Hospitalist, May, p. Researchers cite a number of reasons that many incidents go unreported among them are lack of time, fear of punishment, and confusion about the severity of events that require notification.
Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Hard-and-fast statistics on sentinel events are difficult to come by, however. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment-in that order. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals.
Sentinel events-unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence-can happen anywhere along the healthcare continuum, in any setting. But medication mistakes are just part of the picture. According to a just-released report, Preventing Medication Errors, prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. UWMC paid Church $97,000 after accepting responsibility for the mistake.
When Church complained of unusual post-operative pain, other doctors discovered the retractor during a CAT scan and surgically removed the device soon after. The stainless steel retractor, resembling a metal ruler, slipped from the hands of a distracted doctor during the procedure. If, during the course of conducting survey activities, a potential serious patient safety event is newly identified, the surveyor will take the following steps: n Inform the practice CEO that the event has been identified n Inform the CEO the event will be reported to The Joint Commission for further review and follow-up under the provisions of the Sentinel Event Policy Shading indicates a change.An X-ray shows a 13” long, 2” wide surgical retractor that was accidentally left in the body of Donald Church, 49, of Lynnwood, Wash., by a University of Washington Medical Center (UWMC) surgeon during an operation to remove a tumor on June 6, 2000. The Joint Commission’s Response Patient safety specialists from The Joint Commission assess the acceptability of the practice’s response to the sentinel event, including the thoroughness and credibility of any comprehensive systematic analysis information reviewed and the practice’s corrective action plan. The Joint Commission must receive a request for review of a practice’s response to a sentinel event using any of these options within five business days of the self-report of a sentinel event or of the initial communication by The Joint Commission to the practice that it has become aware of a sentinel event.
Interview and review of relevant documentation including, if applicable, the patient’s medical record, to evaluate the following: n The process the practice uses in responding to sentinel events n The relevant policies and procedures preceding and following the practice’s review of the specific event, and the implementation thereof, sufficient to permit inferences about the adequacy of the practic. Further, reporting the event enables the addition of the “lessons learned” from the event to be added to the Joint Commission’s Sentinel Event Database, thereby contributing to the general knowledge about sentinel events and to the reduction of risk for such events in many other practices.
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