The Joint Commission releases biennial statistics on sentinel events—patient safety events that affect patient outcome and result in death, permanent harm, or severe temporary harm that requires intervention to sustain life. These events are termed “sentinel” because they require immediate investigation and action.
The Joint Commission received 436 sentinel event reports in the first six months of 2019, and the two most frequently reported types of events were surgery-related: unintended retention of a foreign body (URFO), with 60 reported events; and wrong site surgical or invasive procedures, with 29 reported events. The institutions where these events occurred must review them to maintain accreditation and are subject to review by The Joint Commission. These reviews can assist hospitals and other health care institutions in developing quality and patient safety improvement programs.
New reporting categories
The classification system used to describe sentinel events was updated in fall 2018, with the goal of capturing these events in more detail. More specifically, The Joint Commission improved the process for grouping events and accommodated more detailed categories. The latest data comply with the new categories for describing sentinel events, including more specific surgical or invasive procedure events. Of note, burns associated with surgery are differentiated from environmental fire, and wrong site surgery is better differentiated based on site, patient, procedure, and implant. Other new categories are as follows:
- Anesthesia-related events
- Care management events
- Criminal events
- Environmental events
- Product or device events
- Protection events
- Suicide—emergency department
- Suicide—inpatient
- Suicide—offsite within 72 hours
In addition to being the most reported sentinel event in the first half of 2019, URFO was the most reported sentinel event in both 2017 and 2018, with 124 events and 131 events reported, respectively. A review of reported URFO events from 2012 to 2018 in the Joint Commission Journal on Quality and Patient Safety—which included an analysis of the types of objects retained, anatomical regions where the items were left, the care settings, and contributing factors—along with several recommendations on ways to reduce these events.1
Addressing sentinel events
With regard to addressing human factors, the authors recommended the following:1
- Provide team training
- Address disruptive behavior
- Minimize distractions and interruptions
- Account for objects inserted in the wound
- Methodologically explore the surgical site before closure
- Verify the integrity of objects upon removal
- Educate the care team about risk for URFOs, as well as risk-reduction strategies
- Assess competency of personnel
In terms of leadership factors, the commission’s recommendations called for the following:*
- Cultivate a culture of safety
- Conduct a proactive risk assessment
- Implement policies and procedures based on the risk assessment
- Audit and provide feedback of compliance with policies and procedures
- Celebrate successes
- Encourage reporting of near misses
- Recommended communication strategies included the following:1
- Use the whiteboard to demonstrate insertion of devices
- Verbally acknowledge removal of objects
- Discuss removal of objects during standardized debriefing after procedures
- Discuss need for packing removal during handoff
- Minimize nonurgent verbal orders
- Provide written orders for packing removal
- Document verification of removal and integrity of objects
- Issue a best practice alert to remind the team to remove packing materials
Furthermore, wrong site surgery continues to be a commonly reported sentinel event—with 104 events reported in 2017 and 105 events in 2018. To reduce these events, The Joint Commission refers health care professions to several resources, including The Joint Commission’s Universal Protocol,2 The Joint Commission Center for Transforming Healthcare’s Safe Surgery Targeted Solutions Tool®,3 and the World Health Organization Surgical Safety Checklist.4
These resources have well-established procedures and processes that can help prevent wrong patient, wrong site, and wrong procedure events from occurring.
As a note, it is estimated that fewer than 2 percent of all sentinel events are reported to The Joint Commission. Of these, 58.4 percent (8,714 of 14,925 events) have been self-reported since 2005. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.
Health care institutions can learn more about sentinel events on The Joint Commission’s website.
Disclaimer
The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
References
- Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Unintentionally retained foreign objects: A descriptive study of 308 sentinel events and contributing factors. Jt Comm J Qual Patient Saf. 2019;45(4):249-258. Available at: www.jointcommissionjournal.com/article/S1553-7250(18)30304-0/fulltext. Accessed November 4, 2019.
- The Joint Commission. Universal Protocol. Available at: www.jointcommission.org/standards_information/up.aspx. Accessed November 4, 2019.
- The Joint Commission Center for Transforming Healthcare. Safe Surgery Targeted Solutions Tool. Available at: www.centerfortransforminghealthcare.org/en/what-we-offer/targeted-solutionstool/safe-surgery-tst. Accessed November 4, 2019.
- World Health Organization. WHO Surgical Safety Checklist. Available at: www.who.int/patientsafety/safesurgery/checklist/en/. Accessed November 4, 2019.
