Sentinel Event: Characteristics, Differences with Adverse Event and Examples

is defined as sentinel event all that unexpected situation, not related to the natural history of the disease, which puts at risk the physical integrity, health and even the life of the patient. In general, sentinel events have to do with the performance of health personnel.

These events are associated in most cases with human or equipment errors during the health care process. The importance of the correct identification of sentinel events is that most are avoidable when implementing correct action protocols. The goal is for your rate to approach zero.

Checklist for the prevention of sentinel events during surgery

Sentinel events have ethical and legal implications for staff and the institution. Although the execution of every medical act has individual responsibility, the institutions must guarantee the safety of patients. For this, they implement action protocols in each case, as well as adequate supervision measures.

Main characteristics

For an adverse event to be considered a sentinel event, it must meet two fundamental characteristics:

- Produce damage or put the health or life of the patient at risk.

- Being related to a procedure during the health care process, even if it is not a medical procedure in itself.

In this sense the first point is very important, since there is a tendency to catalog any error during patient care as a sentinel event, however insignificant, and that is not correct.

It causes harm or puts the patient at risk

Take the case of a laboratory assistant who will take a blood sample and can not do it at the first puncture, being necessary to try about twice as much.

Undoubtedly this generates discomfort for the patient, but in no case does it jeopardize their health or their life, so that it can not be classified as a sentinel event.

On the contrary, let's see the case in which a patient who was told 3 units of heparin, and instead was given 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.

It is related to an act performed for the health care of the patient

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 table while going to the X-ray table, it is a sentinel event.

As you can see, in both cases it is a fall and in neither event was a medical act in itself (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 study related to health.

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.

Difference between sentinel event and adverse 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 the health personnel.

In contrast, 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 health personnel.

Most common sentinel events

As already mentioned, sentinel events are associated with a human error or a technical failure during the execution of an act directly or indirectly related to health care.

While some sentinel events can be classified as medical malpractice, others do not. Therefore sometimes both terms are confused when in reality at some point they overlap, 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 erroneous procedures.

- Delay in implementing a treatment for any circumstance.

- Confusion in the administration of a medication.

- 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 further, covering a wide range of medical and paramedical acts. This is why monitoring and control of sentinel events is so important.

Likewise, the development of protocols aimed at avoiding human error and equipment failure is of utmost importance. The goal is for sentinel events to approach zero.

Examples

- The patient was cut with a loose sheet of the wheelchair.

- The right eye was operated instead of the left

- A complete trauma surgery was attempted when a damage control was indicated.

- A patient with appendicitis is operated 24 hours after admission because they did not have the materials or personnel to perform the operation before, even though - it was indicated to perform it as soon as possible.

- The patient who receives 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 placed there is a verification failure and each patient receives the globular concentrate that corresponded to the other.

- A patient known as allergic to penicillin receives a dose of this antibiotic.

Quasi-failure

Finally, it is important to mention the quasi-faults. These are nothing more than potential sentinel events that were avoided because the control and supervision protocols worked correctly.

Taking as an example two of the most common sentinel events mentioned previously. It could be that the blood products were going to be administered to the wrong patient; however, given that the transfusion number must be signed by the doctor, the nurse and the bioanalyst, one of the responsible ones noticed and corrected the error.

The same can be applied to the surgery of the wrong eye; in this case it was thought that the right eye was going to be operated, but in the checklist of the instrumentalist and the anesthesiologist it was possible to confirm that the programmed surgery was that of 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.

References

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