Sentinel Event [15-006] (SE)

Date of Publication:

2/17/2011

Definition:

A sentinel event (SE) is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following:     

• Death
• Permanent harm
• Severe temporary harm [defined as: Severe temporary harm is critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition.]
• Suicide of any patient receiving care, treatment, and services in a staffed around-the- clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED)
• Unanticipated death of a full-term infant
• Discharge of an infant to the wrong family
• Abduction of any patient receiving care, treatment, and services
• Any elopement (that is, unauthorized departure) of a patient from a staffed around-the- clock care setting (including the ED), leading to death, permanent harm, or severe temporary harm to the patient
• Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups)
• Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the hospital [Sexual abuse/assault (including rape) as a sentinel event is defined as nonconsensual sexual contact involving a patient and another patient, staff member, or other perpetrator while being treated or on the premises of the hospital, including oral, vaginal, or anal penetration or fondling of the patient’s sex organ(s) by another individual’s hand, sex organ, or object. One or more of the following must be present to determine that it is a sentinel event:

* Any staff-witnessed sexual contact as described above

* Admission by the perpetrator that sexual contact, as described above, occurred on the premises

* Sufficient clinical evidence obtained by the hospital to support allegations of unconsented sexual contact

• Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure (Invasive procedures, including surgery, on the wrong patient, or at the wrong site, or that is the wrong procedure, are reviewable under the policy, regardless of the type of the procedure or the magnitude of the outcome.)
• Unintended retention of a foreign object in a patient after an invasive procedure, including surgery [defined as If a foreign object (for example, a needle tip or screw) is left in the patient because of a clinical determination that the relative risk to the patient of searching for and removing the object exceeds the benefit of removal, this would not be considered a sentinel event to be reviewed. However, in such cases, the organization shall (1) disclose to the patient the unintended retention, and (2) keep a record of the retentions to identify trends and patterns (for example, by type of procedure, by type of retained item, by manufacturer, by practitioner) that may identify opportunities for improvement.]
• Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
• Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose
• Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care [Fire is defined as a rapid oxidation process, which is a chemical reaction resulting in the evolution of light and heat in varying intensities. A combustion process that results in smoldering condition (no flame) is still classified as fire.]
• Any intrapartum (related to the birth process) maternal death or severe maternal morbidity [Severe maternal morbidity is defined, by the American College of Obstetrics and Gynecology, the U.S. Centers for Disease Control and Prevention, and the Society of Maternal and Fetal Medicine, as a patient safety event that  occurs intrapartum through the immediate postpartum period (24 hrs.), that requires the transfusion of 4 or more  units of blood products (fresh frozen plasma, packed red blood cells, whole blood, platelets) and/or admission to the intensive care unit (ICU). Admission to the ICU is defined as admission to a unit that provides 24-hour medical supervision and is able to provide mechanical ventilation or continuous vasoactive drug support],  Additionally, a SE includes any item on the following National Quality Forum Serious Reportable Event (SRE) List (if not already covered by TJC list above):

1. SURGICAL OR INVASIVE PROCEDURE EVENTS

1A. Surgery or other invasive procedure performed on the wrong site 

1B. Surgery or other invasive procedure performed on the wrong patient 

1C. Wrong surgical or other invasive procedure performed on a patient

1D. Unintended retention of a foreign object in a patient after surgery or other invasive procedure

1E. Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient

2. PRODUCT OR DEVICE EVENTS

2A. Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics provided by the healthcare setting

2B. Patient death or serious injury associated with the use or function of a device in patient care, in which the device is used or functions other than as intended

2C. Patient death or serious injury associated with intravascular air embolism that occurs while being cared for in a healthcare setting

3. PATIENT PROTECTION EVENTS

3A. Discharge or release of a patient/resident of any age, who is unable to make decisions, to other than an authorized person

3B. Patient death or serious injury associated with patient elopement (disappearance)

3C. Patient suicide, attempted suicide, or self-harm that results in serious injury, while being cared for in a healthcare setting

4. CARE MANAGEMENT EVENTS

4A. Patient death or serious injury associated with a medication error (e.g., errors involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)

4B. Patient death or serious injury associated with unsafe administration of blood products 

4C. Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy while being cared for in a healthcare setting

4D. Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy

4E. Patient death or serious injury associated with a fall while being cared for in a healthcare setting

4F. Any Stage 3, Stage 4, and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting

4G. Artificial insemination with the wrong donor sperm or wrong egg

4H. Patient death or serious injury resulting from the irretrievable loss of an irreplaceable biological specimen

4I. Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology, or radiology test results

5. ENVIRONMENTAL EVENTS

5A. Patient or staff death or serious injury associated with an electric shock in the course of a patient care process in a healthcare setting 

5B. Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas, or are contaminated by toxic substances

5C. Patient or staff death or serious injury associated with a burn incurred from any source in the course of a patient care process in a healthcare setting

5D. Patient death or serious injury associated with the use of physical restraints or bedrails while being cared for in a healthcare setting

6. RADIOLOGIC EVENTS

6A. Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area

7. POTENTIAL CRIMINAL EVENTS

7A. Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider

7B. Abduction of a patient/resident of any age

7C. Sexual abuse/assault on a patient or staff member within or on the grounds of a healthcare setting

7D. Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of a healthcare setting [Serious is defined by the National Quality Forum as an event that can result in death, loss of a body part, disability, loss of bodily function, or require major intervention for correction (e.g., higher level of care, surgery).]