Review Question - QID 217615

This case of an undetected stroke that occurred because of an oversight in a new process for this hospital is a sentinel event that needs to be remedied so that no additional harm comes to patients as a result of this process.

A sentinel event is terminology defined by the Joint Commission as “any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" that occurs in healthcare. These events represent the first time that a faulty process leads to patient harm and is a signal that the process needs to be modified. Specifically, the Joint Commission says that sentinel events illuminate "any process variation for which a recurrence would carry a significant chance of a serious adverse outcome." These events are named "sentinel" because they frequently indicate the need for an immediate investigation, discovery of the cause, and response.

Rodziewicz et al. present a review article on the types of medical errors and harm that can occur to patients. They discuss how sentinel events are important in detecting flaws in processes that need to be modified.

Incorrect Answers:
Answer 1: Malpractice describes improper, negligent, or illegal activity by a medical practitioner that results in patient harm. In this case, there were no practitioners that were assigned to the patient and the error occurred as the result of systemic oversight (losing track of the patient).

Answer 2: Near miss events describe errors in medical practice that could have resulted in patient harm but did not actually result in harm. In this case, the missed stroke resulted in real harm to the patient. A near miss would be a patient who was not assigned a nurse but did not have a problem overnight.

Answer 3: Negligence describes failure of a healthcare provider to meet the standard of care provided by an average qualified provider. In this case, no provider engaged in any activity because none were assigned to the patient. This case therefore better represents a sentinel event for the healthcare system.

Answer 4: Non-preventable adverse events describe harm that occurs to patients as a result of healthcare interventions despite optimal practice. For example, a deep venous thrombosis that occurs despite a patient being placed on optimal prophylactic therapy is a non-preventable event. In this case, the stroke could have been discovered earlier if a nurse had been assigned to the patient.

Bullet Summary:
A sentinel event is any unexpected occurrence involving death or serious physical or psychological injury that occurs to a patient and indicate areas that require immediate investigation and improvement.