Sentinel and Near Miss Events! Things that you will always hear in your Career
Patient safety is a very important aspect of our career. Remember the Hippocratic Oath? "First, do no harm". Also, such things are questioned in USMLE exams and you need to know something about it. I will be sharing with you some of those concepts:
- Patient safety events are events, incidents or conditions that may or may not have resulted in harm to a patient. It is like an umbrella covering all the events that relate to patient safety.
- Adverse events are events that have resulted in harm to a patient. For example, we try to place a canula on a patient's arm, the patient then gets a hematoma around the puncture site. Another example, placing a Foley catheter for a patient which was traumatic and resulted in red urine. Adverse events can be causing more severe harm than what I have placed as examples.
- Sentinel events are adverse events that have lead to serious physical or psychological injury, death, and not related to the natural course of the patient's illness or underlying condition. I call these events catastrophes. They need immediate investigation and response. Sentinel events include:
1) Non-death events like abduction, rape, assault, suicide or homicide of any patient receiving care or treatment. This includes suicide within 72 hours of hospital discharge.
2) Rape, assault or homicide of any visitor, vendor or staff inside facility
3) Hemolytic transfusion reaction involving a major blood group incompatibilities. We are talking about major blood group not minor. A patient who has blood type A receives blood type B. This is obsolete in this ERA.
4) Performing surgery on the wrong patient, wrong site or leaving an instrument in a patient's body in surgery unintentionally.
5) Any intrapartum maternal death, unanticipated death of full term infant or discharging an infant to the wrong family.
- Near-Miss event is an event that did not produce patient injury or was caught before it happened.
- Root cause analysis is a term that will show up everywhere and usually it is the answer to most questions relating to events. It is an analysis to figure out what happened and study each step in the course of action to see how can you prevent such event from happening again. In simple words, why and how did this happen instead of who did wrong.