Do You Know What A Sentinel Event Is?
A sentinel event is defined as an unexpected incident that is so serious in nature it may cause death, serious physical or psychological injury, or the possibility of such risks. Such events, which signal the need for immediate investigation and response to such an unexpected occurrence, may result in unanticipated death or permanent loss of function not related to the natural course of the patient’s illness or underlying condition.
It is necessary to report and act upon such events if and when they occur. Understanding why a sentinel event occurred, or assessing the “root cause” of such an event, will enable the hospital to make appropriate changes to ensure that it will not occur again. Specific means of improvement are identified, and specific plans—such as changes in the hospital’s systems and processes—may be put in place to prevent a similar event from happening in the future.
If a sentinel event occurs, it should be reported directly to a supervisor and an incident report should be completed. (The use of e-mail is not recommended in situations where clinical events or patient names are revealed.) Other ways to report an incident are through the Hospital Risk Manager (ext. 8394) or the Compliance Help Line (ext. 8907).
BWH encourages reporting, as a positive step that contributes to our goal of improving patient care, and reporting an event will not reflect negatively upon any person or staff. It helps in the understanding of how and why these events occur, and in the prevention of a recurrence. However, it is important that any such incident is neither discussed nor concealed. All events are treated confidentially unless it is necessary to make a report to
an outside agency.
Contact Karen Nelson (ext. 5810) or Janet Barnes (ext. 8394) for more information.