A sentinel event is "any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness". [1] Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed, and that undesirable trends or decreases in performance are caught early and mitigated.
Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof". [1] They also include the following, even if death or major loss of function did not occur:
In addition to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis.
Type of event | Number of events |
---|---|
Unintended Retention of a Foreign Body | |
Wrong–patient, wrong-site, wrong-procedure | |
Suicide | |
Fall | |
Delay In Treatment | |
Op/Post-op Complication |
Participation is necessary by the leadership of TJC accredited healthcare organizations and by the persons closely involved in the systems under review. Causal factors are analyzed, focusing on systems and processes, not individual performance. Potential improvements, called an "action plan", are identified and implemented to decrease the likelihood of such events in the future. Each accredited organization is encouraged, but not required, to report any sentinel event to The Joint Commission. However, the organization is expected to prepare a root cause analysis and action plan within 45 calendar days of the event. In addition, healthcare organizations are required to notify the Food and Drug Administration (FDA) and device manufacturers within 10 days of a sentinel event caused by a medical device, according to the Safe Medical Device Act of 1990. Statistics of sentinel events are recorded and published by the FDA's MedWatch program.
Advantages of reporting sentinel events to The Joint Commission are:
After review of the accredited facility's report on the sentinel event, The Joint Commission issues an Official Accreditation Decision Report that may modify the organization's current accreditation status, assign an appropriate "measure of success", or a require follow-up survey within six months. A healthcare facility that fails to complete a root cause analysis of the sentinel event and action plan within the time frame can be placed on "Accreditation Watch" by the Joint Commission, a status that can be publicly disclosed. The Joint Commission disseminates "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence. [5]
Further nursing research is ongoing at a number of "magnet" hospitals in the United States, especially to reduce the number of patient falls that may lead to sentinel events.
Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical and industrial radiography. Similar techniques are used in airport security,. To create an image in conventional radiography, a beam of X-rays is produced by an X-ray generator and it is projected towards the object. A certain amount of the X-rays or other radiation are absorbed by the object, dependent on the object's density and structural composition. The X-rays that pass through the object are captured behind the object by a detector. The generation of flat two-dimensional images by this technique is called projectional radiography. In computed tomography, an X-ray source and its associated detectors rotate around the subject, which itself moves through the conical X-ray beam produced. Any given point within the subject is crossed from many directions by many different beams at different times. Information regarding the attenuation of these beams is collated and subjected to computation to generate two-dimensional images on three planes which can be further processed to produce a three-dimensional image.
Medical physics deals with the application of the concepts and methods of physics to the prevention, diagnosis and treatment of human diseases with a specific goal of improving human health and well-being. Since 2008, medical physics has been included as a health profession according to International Standard Classification of Occupation of the International Labour Organization.
In science and engineering, root cause analysis (RCA) is a method of problem solving used for identifying the root causes of faults or problems. It is widely used in IT operations, manufacturing, telecommunications, industrial process control, accident analysis (e.g., in aviation, rail transport, or nuclear plants), medical diagnosis, the healthcare industry (e.g., for epidemiology), etc. Root cause analysis is a form of inductive inference (first create a theory, or root, based on empirical evidence, or causes) and deductive inference (test the theory, i.e., the underlying causal mechanisms, with empirical data).
Medical tourism is the practice of traveling abroad to obtain medical treatment. In the past, this usually referred to those who traveled from less-developed countries to major medical centers in highly developed countries for treatment unavailable at home. However, in recent years it may equally refer to those from developed countries who travel to developing countries for lower-priced medical treatments. With differences between the medical agencies, such as the Food and Drug Administration (FDA) or the European Medicines Agency (EMA), etc., which decide whether a drug is approved in their country or region, or not, the motivation may be also for medical services unavailable or non-licensed in the home country.
The Joint Commission is a United States-based nonprofit tax-exempt 501(c) organization that accredits more than 22,000 US health care organizations and programs. The international branch accredits medical services from around the world.
Outpatient surgery, also known as ambulatory surgery, day surgery, day case surgery, or same-day surgery, is surgery that does not require an overnight hospital stay. The term “outpatient” arises from the fact that surgery patients may enter and leave the facility on the same day. The advantages of outpatient surgery over inpatient surgery include greater convenience and reduced costs.
A biomedical engineering/equipment technician/technologist or biomedical engineering/equipment specialist is typically an electro-mechanical technician or technologist who ensures that medical equipment is well-maintained, properly configured, and safely functional. In healthcare environments, BMETs often work with or officiate as a biomedical and/or clinical engineer, since the career field has no legal distinction between engineers and engineering technicians/technologists.
An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality management purposes such as to look at bad outcomes and determine whether there was any mis-diagnosis, mistreatment or any systemic problems involved which led to the sentinel event.
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.
A patient safety organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery
Corrective and preventive action consists of improvements to an organization's processes taken to eliminate causes of non-conformities or other undesirable situations. It is usually a set of actions, laws or regulations required by an organization to take in manufacturing, documentation, procedures, or systems to rectify and eliminate recurring non-conformance. Non-conformance is identified after systematic evaluation and analysis of the root cause of the non-conformance. Non-conformance may be a market complaint or customer complaint or failure of machinery or a quality management system, or misinterpretation of written instructions to carry out work. The corrective and preventive action is designed by a team that includes quality assurance personnel and personnel involved in the actual observation point of non-conformance. It must be systematically implemented and observed for its ability to eliminate further recurrence of such non-conformation. The Eight disciplines problem solving method, or 8D framework, can be used as an effective method of structuring a CAPA.
Due to the near-universal desire for safe, effective, and high quality healthcare, there is a growing interest in international healthcare accreditation. Providing healthcare, especially of an adequate standard, is a complex and challenging process. Healthcare is a vital and pervasive issue; it influences all aspects of societies. It has medical, social, political, ethical, business, and financial ramifications. In any part of the world healthcare services can be provided either by the public sector or by the private sector, or by a combination of the two. Healthcare can be provided in hospitals or be accessed through practitioners working in the community, such as general medical practitioners and dental surgeons.
Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”. Critically, accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process. There are parallel issues in evidence-based medicine, quality assurance and medical ethics, and the reduction of medical error is a key role of the accreditation process. Hospital accreditation is therefore one component in the maintenance of patient safety. However, there is limited and contested evidence supporting the effectiveness of accreditation programs.
A never event is the "kind of mistake that should never happen" in the field of medical treatment. According to the Leapfrog Group never events are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability."
Medical equipment management is a term for the professionals who manage operations, analyze and improve utilization and safety, and support servicing healthcare technology. These healthcare technology managers are, much like other healthcare professionals referred to by various specialty or organizational hierarchy names.
Hamad Medical Corporation (HMC) is Qatar’s main not-for-profit health care provider, and is based in Doha. It was established by Emiri Decree No. 35 in 1979. HMC manages several hospitals, as well as emergency, specialized, and ambulatory care centers, and operates both the national ambulance service and a home healthcare service.
Critical Test Results Management (CTRM) also known as Critical Test Results Reporting, and Closed-Loop Reporting, is the software that handles a medical test result that has come back as critical to a patient’s health. CTRM software prevents the critical result from being lost in communication failures, improves patient safety, and documents the delivery of the results.
Adventist HealthCare White Oak Medical Center is a hospital with 180 private patient rooms and serves patients in Montgomery, Prince George's, and surrounding counties.
Radiation Exposure Monitoring (REM) is a framework developed by Integrating the Healthcare Enterprise (IHE), for utilizing existing technical standards, such as DICOM, to provide information about the dose delivered to patients in radiology procedures, in an interoperable format.
Credentialing is the process of establishing the qualifications of licensed medical professionals and assessing their background and legitimacy.