I was sitting in a small conference room. Having worked full-time as hospital Chief Medical officer, I was now interviewing for a position in a larger institution. Midway through my interviews, I was talking with the hospital board chairman. He brought up the topic of hospital sentinel events. Apparently there had been a sentinel event at his organization and the chair and his board were quite concerned.

He explained that it was something they had not experienced before. They were upset that such an event could occur at their facility. He asked me to describe what I knew about hospital sentinel events and share some of my experiences.

Here is a short list of what I told him:

• In the hospital setting, a sentinel event is a specific term defined by The Joint Commission. It is a very serious, uncommon patient safety event that occurs when multiple systems break down that  results in harm to a patient.
• Not to minimize what may have happened at his facility, I told him that every hospital experiences sentinel events.
• Because they are so serious, in addition to harming a patient, they often result in upset staff and physicians, and angry patients and families. Allegations of medical negligence and potential public relations problems can occur following such an occurrrence.

I also explained that a good-sized community hospital might experience 6 to 12 sentinel events annually, in my opinion.

He seemed a bit shocked by that estimate.

I reminded him not all SEs are of the same severity. There is a difference between a “never event” such as wrong site surgery or a fire occurring in the operating room, and a medication error that causes temporary, albeit serious, harm to a patient.

Recent TJC Statistics on Hospital Sentinel Events

TJC has developed its approach to defining, identifying, analyzing and reporting sentinel events over several decades. Part of that process includes the voluntary reporting of sentinel events by accredited hospitals. When reporting the SE, most hospitals follow-up with TJC by submitting the results of its root cause analysis of the event.

We adopted a policy of reporting almost every sentinel event to TJC that we experienced. We believed that the additional support and coaching provided by TJC following our RCAs were very valuable. Also, it could be embarrassing if our board or the public discovered that there had been a serious SE that had not been reported to TJC, if and when it came to light.

This type of voluntary reporting allows TJC to track trends in SE occurrences and to promote preventive measures to reduce their occurrence. According to published TJC reports, for each of the past five years, about 900 such events were self-reported. There were another 200 or more that were reported to TJC in other ways (anonymous reports, media reports, etc.).

If we assume that as few as 5% to 10% of SEs are reported to TJC, then there are probably 9,000 to 18,000 such events annually in U.S. hospitals; more if you include less serious occurrences. With about 5,000 non-psychiatric, non-federal hospitals in the U.S., that would equate to 2 to 4 serious events per year per hospital.

There is a fairly consistent pattern to the types of events seen in hospitals.

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These numbers are probably skewed by the fact that retained FB and wrong site surgery are very obvious and easily measurable. But other events are more subjective with regard to their seriousness and reportability. For example, it is doubtful that every organization defines a “serious medication error” in the same way. Some will have a higher threshold for reporting such events than others.

There is also a fairly consistent pattern to the types of outcomes each year.

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Responding to Sentinel Events

When a sentinel event is identified, the appropriate response is to perform a root cause analysis (RCA). The RCA process was developed first in the field of engineering in the 1950s. It’s development is often attributed to Sakichi Toyoda, the founder of the Toyota Corporation.

The concept of sentinel events and RCAs were not applied to medical care until decades later. But their use is now widespread, being promoted by both TJC and the Centers for Medicare and Medicaid (CMS) as a way to learn from and prevent future patient safety breakdowns.

Most physicians do not welcome being asked to participate in an RCA, however. They are time-consuming. And the atmosphere of an RCA meeting can be intimidating and uncomfortable as participants frankly describe breakdowns leading to a patient's harm.

Why Pay Attention to Sentinel Events

Given that sentinel events have the effects mentioned above (patient harm, liability, increased costs, psychological trauma to involved professionals), it should be clear that these events must be addressed aggressively.

As a hospital leader responsible for patient quality and safety, here are some of the reasons I believe medical staff leaders and physician executives should become experts at recognizing and investigating a sentinel event:

1. Leaders Can Demystify the Process.

Because sentinel events and ensuing RCAs are, thankfully, uncommon, most healthcare workers rarely become involved. It is therefore essential that the leaders in an organisation remove the fear of being part of an RCA, and effectively communicate the need to openly, and in a blame-free manner, try to identify the root causes of an event.

While the core expertise in running an RCA may lie in Quality or Patient Safety Staff, the physician executive must feel comfortable with the process. He or she can then help to encourage others involved in an SE to provide feedback and input.

2. Leaders Promote a Culture of Safety.

The culture of an organization is often described as “how we do things around here.” Physician leaders must set the agenda AND model the behaviors that promote such a culture of patient safety. This culture has the following characteristics:

• Employees are empowered to question unsafe practices;
• Everyone understands that healthcare is prone to error;
• Lifelong learning and continuous improvement are valued; and,
• Teamwork is crucial to improving safety.

3. Leaders Enable and Support Improved Patient Care.

Identifying a sentinel event, performing a root cause analysis, and instituting corrective measures based on the RCA will reduce the likelihood of occurrence in the future. This will make your hospital a safer place for your patients.

4. Leaders Foster Downstream Benefits.

Better patient care means less rework, lower liability costs, and better staff morale. A safe high quality hospital fosters pride in caregivers, medical staff and board, and better standing in the community. By avoiding staff turnover and expensive lawsuits, there is a positive financial result in the long run.

5. Only Physician Leaders Can Fully Engage Other Physicians in the Process.

I wrote about the challenges of achieving and maintaining physician engagement in Become a Physician Leader and Save the Medical Profession. It can be quite difficult for non-physician CEOs, Quality Directors and other hospital management to speak the physician's language and enroll them in patient safety initiatives, including an RCA following a sentinel event.

None of us wants to accept the occurrence of hospital sentinel events. Hence, it should be our goal to promote the aggressive investigation of and learning from sentinel events.

How Can Leaders Help?

Here are some things we can do to help the process:

• Make time to participate in and co-lead RCAs if possible.
• Bring learnings from completed RCAs to the medical staff for discussion and feedback.
• Provide education about SEs and RCAs to your hospital board.
• Provide the board with an annual summary of RCAs that lists the nature of the events and the changes implemented to reduce or eliminate their occurrence in the future.

Next Steps

If you are not already involved with RCAs, seek out the professional at your organization that oversees identification of sentinel events. This might be the Director of Quality, or Patient Safety, or Risk Management. Then talk with them. Ask about the process if you're not already involved. And ask if you can sit through a root cause analysis or two to understand the process better.

Review These Additional Resources

Here is the TJC Sentinel Event Policy and List of Sentinel Events.

For an overview of the root cause analysis process go to Guidance for Performing Root Cause Analysis from CMS.

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