SENTINEL EVENTS
GROUP 6
Team
Dr. Amit Joshi
Reviewed by Dr. Nilesh Binjwa
Dr. Lallu Joseph
Secretary General Ms. Jenifer R Kuruvilla
CAHO [Link] Pinky
Introduction
An unexpected incident, related to system or process
deficiencies, which leads to death or major and enduring loss
of function for a recipient of healthcare services.
Loss of function refers to sensory, motor, physiological, or
psychological impairment not present at the time services
were sought or begun
Contd..
A sentinel event is a Patient Safety Event that reaches a
patient and results in any of the following:
Death
Permanent harm
Severe temporary harm and intervention required to sustain
life
TYPES OF SENTINEL EVENTS
Surgical Events - wrong body part/ patient/ procedure, retained
instrument, death during the procedure, anesthesia related events
Device or Product events - contaminated drugs and device,
breakdown or failure
Patient protection events - attempted suicide, intentional injury,
nosocomial infection
Environmental events - burn, slip, fall, electric shock
Care management events - hemolytic reaction, medication errors
Criminal events - abduction, sexual assault, physical assault on the
grounds of healthcare facility
ROOT-CAUSE ANALYSIS AND ACTION
PLAN
Organization should conduct a root-cause analysis to identify
contributing factors within 45 days of a sentinel event or
becoming aware of the event.
This analysis focuses on systems and processes, not individual
performance.
All persons involved with the event in any way should
participate in the analysis, as each may have important
insights and observations.
The sooner root-cause analysis takes place, the better—while
the circumstances are fresh in participants’ minds.
Why do Sentinel event occur
Systemic problems rather than the mistake of an individual
Inadequate communication between healthcare provider and
patient
Incorrect assessment of Patients condition
Inadequate training and orientation
Expectations from Organization
Root cause analysis
Process to identify basic or causal factors of Sentinel event in
future
Action plan
Plan to identify strategies to implement reduce risk of
Sentinel event
Survey process
Evaluate the facilities compliances with applicable standards
Training frequency
To be incorporated in Induction module of all new joiners in
HCO.
To be incorporated in the routine training schedule
Pre and post training evaluation to assess the knowledge level
of trainees.
Targeted audience
Nursing staff
Consultants/RMO/Paramedical workers
Security/Cafeteria personals
House keeping staff
Maintenance department personals
Suggestions
Proper and timely reporting of Sentinel event in HCO is to
be encouraged
CAPA should be implemented as an priority to prevent
future risks
Proper implementation of different checklists.
Involvement of multi disciplinary team for RCA and CAPA
Thank You
