A sentinel event is any unanticipated event that may occur in the hospital setting resulting in death or serious injury, mental or physical, to a patient or a group of patients. The characteristic mark of a sentinel event is that it is not directly related to the nature or course of the illness of a patient. Sentinel events can occur due to medical errors, but just as not all medical errors lead to sentinel events, not all sentinel events are caused by medical errors.
In the manner a major overlap exists between iatrogenic events and medical errors, both sentinel events and medical errors cover a lot of the same ground. In the English language, the word ‘sentinel’ means sentry or guard at a gate. The sentinel events are so-called because they alert us to wake up and investigate a situation. In 1998, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has defined a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.
” We have to notice the phrase “the risk thereof” here. This phrase implies that not only the actual event of injury or death but the possibility of it can also be considered as a sentinel event, since even the detection of the possibility of things going wrong can alert us to serious harm that could surface in the future. Sentinel events occur when there is a variation in the standard process. That is to say, a physician is supposed to do a certain thing in a certain way, but if he does it in another way it is called a process variation.
All process variations of course do not lead to serious harm, but some definitely do. Therefore a sentinel event could also refer to a process variation which if repeated could entail significant risk although it has not yet resulted in any harm. For example, a nurse may be giving a patient overdose consistently for several days. This has not yet resulted in any harm in the patient, so a sentinel event has not yet occurred, but the risk of the sentinel event happening is represented by this process variation, i. e.
, the administering of excessive dose — therefore this process variation itself can be considered a sentinel event, technically speaking. Sentinel events, just like medical errors and other iatrogenic events, can be caused either by commission or omission. The difference between a medical error and a sentinel event can be grasped from what has been traditionally the most common and the most prominent sentinel event: inpatient suicide. As we can imagine, suicides can occur because of medical errors or they can happen because of a variety of other reasons.
For example, a patient might commit suicide from the trauma resulting from being operated while he or she was not properly anaesthetized — which is a medical error. Or a person may commit suicide simply because of the insufferable anguish of an illness. Either way it is a sentinel event because it is something that is not supposed to happen. Both types of sentinel events are preventable in theory, such as by counseling etc. The purpose of the medical establishment is to do everything it can do to promote a patient’s health and well-being, therefore even the responsibility of a patient’s suicide has to be assumed by the hospital.
In one study, the JCAHO has investigated 983 sentinel events of which 188 were inpatient suicides, 126 were events associated with medication errors, and 119 represented post operative complications. Following the top three are: events of surgery at the wrong site, deaths related to delay in treatment, patient falls from multistoried buildings, assault, rape or homicide, deaths of patients in restraints, deaths following patient elopement, transfusion-related events, perinatal death or injury, infant abductions, fires — in that order.
Besides these, 167 events were attributed to miscellaneous causes. As we can see, most of these sentinel events may or may not be caused by medical errors. Only ‘medication errors’, ‘events of surgery at the wrong site’ and ‘deaths related to delay in treatment’ are almost always caused by medical error. Hospitals need to pay attention to both sentinel events and medical errors.