Clinical Incidents & Sentinel Events

As a healthcare provider, it is your duty and responsibility to promptly report any unsafe condition, sentinel event or unusual event that can result in a sentinel event. Everyone is expected to participate in maintaining a safe environment for patients, visitors, physicians and their coworkers. This means taking an active role in reporting any and all unsafe conditions, unusual or sentinel events. All such events should always be reported immediately to your charge nurse, nursing supervisor and Guardian Angel’s President or Clinical Liaison.

Clinical staff must recognize the importance of following effective procedures and are encouraged to speak up if something has compromised or might compromise patient safety and quality.

A Clinical Incident is any event or series of events that resulted in or had the potential to result in an adverse patient outcome. Clinical staff should notify their Charge Nurse, Nursing Supervisor, and Guardian Angel of any clinical incidents that occur while on assignment, regardless of an adverse outcome.

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

Such events are called “sentinel” because they signal the need for immediate investigation and response.

Examples of Clinical Events • Omission of treatment • Deviation from policy • Medication errors • Improper equipment usage • IV or Blood complications • Patient fall • Inaccurate clinical assessment • Patient or physician complaint

Examples of Sentinel Events • Any patient death, paralysis, coma or other major permanent loss of function associated with a medication error • A patient commits suicide within 72 hours of being discharged from a hospital setting that provides staffed around-the-clock care. • Any elopement, that in unauthorized departure, of a patient from an around-the-clock care setting resulting in a temporally related death (suicide, accidental death, or homicide) or major loss of function. • A hospital operates on the wrong side of the patient’s body. • Any intrapartum (related to the birth process) maternal death. • Any perinatal death related to a congenital condition in an infant having a birth weight greater than 2500 grams. • A patient is abducted from the hospital where he or she receives care, treatment or services. • Assault, homicide, or other crime resulting in patient death or major permanent loss of function. • A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall • Hemolytic transfusion reaction involving major blood group incompatibilities • A foreign body, such as a sponge or forceps that was left in a patient after surgery

Joint Commission’s Sentinel Event Policy The Joint Commission has defined a sentinel event policy that you should be aware of.

This policy has four goals: 1. To have a positive impact in improving patient care, treatment and services and preventing sentinel events 2. To focus the attention of an organization that has experienced a sentinel event on understanding the root causes that underlie the event, and on changing the organization’s systems and processes to reduce the probability of such an event in the future. 3. To increase the general knowledge about sentinel events, their causes, and strategies for prevention. 4. To maintain the confidence of the public and accredited organizations in the accreditation process

Guardian Angel Staffing Agency, Inc., is a Joint Commission Accredited Health Care Staffing Agency License #450626 that supports the mission of the Joint Commission to continuously improve the safety and quality of care provided to the public through the support of performance improvement in healthcare organizations.