Sentinel Events and Near Misses

• Adopted by Dr. Haitham Khatatbeh

• Jerash University- Faculty of Nursing
What is a Sentinel Event?
• The Joint Commission defines a sentinel event as an
unexpected occurrence involving death, serious physical or
psychological injury. Sentinel events can result from errors of
omission or commission.

• The event can result in death, permanent harm, or severe,

temporary harm.
• The term sentinel refers to a system issue that may result in
similar events in the future.
Prevalence of sentinel events
• Sentinel events occur in every healthcare setting.

• The difference between an excellent hospital and a poor one is

that the excellent hospital continuously tries to improve its
systems and processes to understand and eventually reduce
the number of its sentinel events.
Australian sentinel events
1. Surgery or other invasive procedure performed on the wrong site
resulting in serious harm or death
2. Surgery or other invasive procedure performed on the wrong
patient resulting in serious harm or death
3. Wrong surgical or other invasive procedure performed on a patient
resulting in serious harm or death
4. Unintended retention of a foreign object in a patient after surgery
or other invasive procedure resulting in serious harm or death
5. Haemolytic blood transfusion reaction resulting from ABO
incompatibility resulting in serious harm or death
Continue…
6. Suspected suicide of a patient in an acute psychiatric unit or acute
psychiatric ward
7. Medication error resulting in serious harm or death
8. Use of physical or mechanical restraint resulting in serious harm or
death
9. Discharge or release of an infant or child to an unauthorised person
10. Use of an incorrectly positioned oro- or naso- gastric tube resulting
in serious harm or death
 Sentinel events vs near misses
• Actual Event - when a sentinel event or adverse event actually
happens;

• Near Miss Events – when a sentinel event almost happened but was
caught in the nick of time; a process deviation that did not affect
outcome, but a recurrence carries significant chance of a serious
adverse outcome.
 Types of near misses
1. Planned detection and recovery – Here, detection is a process step.
E.g. A lab specimen was examined for lipemia as required (planned
detection) . Lipemia was found and the sample underwent an
ultracentrifuge step (planned, successful recovery) before analysis.

2. Chance detection – Detection occurred only by chance. Example – A

portable BP monitor was disconnected during an MRI. The BP
monitor was then incorrectly reconnected to the IV line. A family
member noticed the incorrect connection (chance detection) and
called a nurse who corrected the problem (unplanned, successful
recovery).
Continue.. Types of near misses
3. Unsafe situation (Accident waiting to happen) – An error event is
only recognized as such after a chance detection. Example – Two
similar looking medications are next to each other. If an incorrect
selection is made, the result could be fatal. Placing the similar
medications next to each other can be considered to be a process
error event. This error event may be a cause for selection of the
incorrect medication. If the wrong medication is selected and this
error is detected before administering the medication (chance
detection and unplanned, successful recovery), a near miss has
occurred.
Response to a Sentinel Event
• The hospital must review all sentinel events.
• All JCI accredited hospitals are encouraged but not obligated to report
to the Joint Commission every sentinel event.
Around 800 sentinel events are reported to the Joint
Commission every year.
How to contain a sentinel event?
1. Stabilize the patient: immediate containment action as needed
2. PRESERVE the Evidence: Isolate all involved machinery (pumps, anesthesia
machines) and preserve settings, Isolate all involved medication equipment
(syringes, IV tubing, medication vials)
3. DOCUMENT in the Medical Record: Include only verifiable facts about the
event, care given in response and new care plans. DO NOT include
subjective feelings or beliefs, events which you did not personally witness,
hearsay evidence.
4. Plan for timely PATIENT DISCLOSURE. Why disclose? Patients have the right
to know. Who will disclose? The AP is responsible for disclosure. The
hospital may form a team to assist him in planning for the disclosure. When
to disclose? As promptly as the patient’s condition will allow. Timely
disclosure rebuilds a patient’s trust.
5. Immediate investigation
How is a sentinel event investigated?
➢ Hospital organizes a small team of leaders to analyze the event with
those involved
➢ The focus of the analysis is NOT to assign blame but to
search for underlying causes.
➢ Comprehensive systematic review
➢ Root cause analysis (RCA) for identifying the causal and contributory
factors
Patient safety investigation
methodologies
• All incidents (with the highest severity rating) should undergo an in-depth
investigation. There are a range of investigation methodologies used, the
most common are:

1. Root Cause Analysis;

2. London Protocol;
3. Failure Modes and Effects Analysis.

• For review of low severity incidents and near misses, less resource
intensive tools are used, for example, After-Action Review, Debriefing and
Huddles, and Swarm
1. Root Cause Analysis
• Root Cause Analysis (RCA) is a systematic process that attempts to
answer three questions about an incident:

1. What happened?
2. Why did it happen?
3. How can we prevent it happening again?
Continue..
• RCA brings together a small team of diverse set of individuals who are
independent to the incident.
• RCA represents a toolbox of approaches rather than a single method.
More than 40 RCA techniques are described in literature, including
brainstorming and cause-effect charts.
• The end point of an RCA is a set of recommendations for an
organisation to implement to reduce harm to patients in the future.
• Aggregating findings from multiple RCAs, other incident investigations
and other data sources can be used to identify future risks and
proactively develop improvement programs.
2. London Protocol
• The London Protocol takes a systems approach to incident
investigation.

• It provides a structure for interviews and the search for information.

The interview questions focus on the chronology of the incident:
1. care delivery problems;
2. contributory factors.
3. Failure Mode and Effect Analysis
• Failure Mode and Effect Analysis (FMEA) is a systematic method of
identifying clinical problems before they occur.
• FMEA does not rely on something going wrong as the trigger for an
investigation.
• It involves proactive hazard analysis and identifying actions to
mitigate the risks. The key questions considered during hazard
analysis include:
➢ What could go wrong?
➢ Why would the failure happen?
➢ What would be the consequence of each failure?
FMEA uses
❖ Evaluating a new process prior to implementation;

❖ Assessing the impact of a proposed change to an existing process;

❖ System redesign of high-priority processes where the consequence of

failure can be high (for example, radiotherapy or blood transfusion).
Barriers for using FMEA

▪ FMEA is time consuming and resource intensive. On average one

FMEA requires six to eight meetings of 1.5 hours duration with
around eight participants.

▪ Topics should be well-defined and scoped and there should be

reasonable certainty that they are high risk if an investment in FMEA
is to be undertaken.
Reporting sentinel
events
When do you report?
1. Actual Event - when a sentinel event or adverse event actually
happens
2. Near Miss Events – when a sentinel event almost happened but
was caught in the nick of time; a process deviation that did not
affect outcome, but a recurrence carries significant chance of a
serious adverse outcome
3. Unsafe Conditions – that might predispose to the sentinel
event, including:
a. Medical Device Issues
b. Medical Care issues
c. Nursing Care issues
When do you report For example, for
medication incident
• Actual Event - when a wrong dose of insulin is given
• Near Miss Events – when a wrong dose of insulin was caught
just before administration
• Unsafe Conditions:
• Medical Device Issues – faulty insulin pump
• Medical Care issues – illegible orders
• Nursing Care issues – poorly labeled insulin vials
Questions?