A sentinel event It is all that unexpected situation, not related to the natural history of the disease, that puts the physical integrity, health and even the life of the patient at risk. Sentinel events are generally related to the performance of health personnel.
These events are associated in most cases to human or equipment errors during the healthcare process. The importance of the correct identification of sentinel events is that most of them are avoidable by implementing correct action protocols. The goal is for your rate to approach zero.
Sentinel events have ethical and legal implications for staff and the institution. Although the execution of any medical act has individual responsibility, the institutions must guarantee the safety of the patients. For this, they implement action protocols in each case, as well as adequate supervision measures..
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For an adverse event to be considered a sentinel event, it must meet two fundamental characteristics:
- Produce harm or endanger the health or life of the patient.
- Being related to a procedure during the health care process, even if it is not a medical procedure itself.
In this sense, the first point is very important, since there is a tendency to classify any error during patient care as a sentinel event, no matter how insignificant, and that is not correct.
Take the case of a laboratory assistant who is going to take a blood sample and cannot do it on the first puncture, making it necessary to try two more times..
Undoubtedly, this generates discomfort for the patient, but in no case does it put their health or life at risk, so that it cannot be classified as a sentinel event.
On the contrary, let's look at the case in which a patient who was prescribed 3 units of heparin, and instead is administered 3 units of insulin because the bottles were confused.
In this case, the administration of insulin can induce hypoglycemia in a non-diabetic patient and could lead to death. Therefore, this is a sentinel event.
If a patient falls out of bed at home receiving a given medication, it is an adverse event, but if the fall occurs from the stretcher while moving to the X-ray table, it is a sentinel event..
As can be seen, in both cases it was a fall and in neither event was a medical act itself taking place (injection, surgery, study, etc.). However, in the second case it is a sentinel event, since it occurred in a transfer within a health institution to carry out a health-related study.
As the fall is capable of causing damage to the health and life of the patient, the second fall meets the two conditions to qualify as a sentinel event.
Sentinel events are characterized by being generated within the framework of a medical intervention and depend on the conditions of the medical environment and the performance of healthcare personnel.
On the other hand, adverse events have variables linked to the patient and his reaction (biological variables), as well as to environmental elements that are beyond the control of healthcare personnel..
As already mentioned, sentinel events are associated with human error or technical failure during the execution of an act related directly or indirectly to health care..
While some sentinel events can be classified as medical malpractice, others cannot. For this reason, both terms are sometimes confused when in fact they overlap at a certain point, but they are not the same.
Among the most common sentinel events are:
- Patient falls.
- Injuries caused by equipment malfunction.
- Surgeries in the wrong place.
- Performing wrong procedures.
- Delay in implementing a treatment due to any circumstance.
- Confusion in the administration of a medicine.
- Administration of blood products that were intended for another patient.
- Indication and / or administration of contraindicated medications.
The list is long and can be extended even further, covering a wide range of medical and paramedical acts. This is why the monitoring and control of sentinel events is so important..
Likewise, the development of protocols aimed at avoiding human error and equipment failure as much as possible is of utmost importance. The goal is for sentinel events to get close to zero.
Some examples of sentinel events are:
- The patient was cut with a loose blade from the wheelchair.
- The right eye was operated instead of the left.
- Complete trauma surgery was attempted when damage control was indicated.
- A patient with appendicitis is operated on 24 hours after admission because there were no materials or personnel to perform the operation before, even though - it was indicated to perform it as soon as possible.
- The patient receiving insulin instead of heparin.
- It may be the case that two globular concentrates arrive: A for patient 1 and B for patient 2. But when they are to be placed there is a verification failure and each patient receives the globular concentrate that corresponded to the other.
- A patient known to be allergic to penicillin receives a dose of this antibiotic.
Finally, it is important to mention quasi-faults. These are nothing more than potential sentinel events that were avoided because the monitoring and control protocols worked properly..
Taking as an example two of the most common sentinel events mentioned previously. It may be that the blood products were going to be given to the wrong patient; However, since the transfusion number must be signed by the doctor, the nurse and the bioanalyst, one of those responsible noticed and corrected the error.
The same can apply to wrong eye surgery; In this case, it was thought that the right eye was going to be operated on, but the scrutiny and anesthesiologist's checklist showed that the scheduled surgery was for the left eye, thus avoiding a serious error.
In both cases, the events are classified as quasi-failures, considering that it was an aborted sentinel event due to the correct execution of the control measures..
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