What are Sentinel Events? (And How to Reduce Them)

Note: This blog was updated in July 2022 with more current data on number and types of sentinel events.

Even in the top-functioning, best-maintained hospital facilities, medical errors can happen. The worst-case scenarios are when a patient is seriously injured (permanently or temporarily) or even killed. These events are called “sentinel” events, so called because they signal a need for immediate investigation or response.

Concerning Rise in Sentinel Events

Serious patient safety incidents unfortunately appear to be on the rise today in hospitals. The Joint Commission, the nation’s oldest and largest standards-setting and accrediting body in health care, first started tracking sentinel events in 2007. The organization recently reported that 2021 included the highest annual levels seen since.

Most Common Types of Sentinel Events

In 2021, The Joint Commission received 1,197 reports of sentinel events, a 48% increase over 2020. According to the accrediting body, 89% of these incidents were self-reported voluntarily by an accredited or certified entity. The remaining 129 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization.

The Top 10 most frequently reported sentinel events in 2021 include:

• Fall (485 incidents)
• Delay in treatment (97 incidents)
• Unintended retention of a foreign object (97 incidents)
• Wrong-site surgery (85 incidents)
• Suicide (79 incidents)
• Self-harm (45 incidents)
• Fire (38 incidents)
• Medication management (35 incidents)
• Assault (34 incidents)
• Clinical alarm response (22 incidents)

The Joint Commission points out that less than 2% of all sentinel events are actually reported, so this data set should be with that caveat. However, reviewing the data from 1995 to present, some trends in the serious impact of sentinel events can be identified.

• 46% of sentinel events led to a patient’s death
• 24% led to unexpected additional care
• 12% led to severe temporary harm
• 6% led to permanent loss of function
• 2% led to permanent harm
• 2% led to a psychological impact

What to Do If You Have a Sentinel Event

If you find yourself facing a sentinel event in your hospital, The Joint Commission offers a 5-step process of what to do next.

1. Secure the situation, first and foremost. Ensure the immediate safety and wellbeing of anyone directly involved, including patients and staff.
2. Preserve anything that might be helpful in the analysis process, including equipment, medication, and more. You may choose to take photos of the scene of the sentinel event to aid in downstream analysis.
3. Disclose situationally relevant information to the patient or his or her designated caregiver as soon as possible.
4. Provide support for patients, family members, and staff. Sentinel events have many victims, so a comprehensive support system of services is essential.
5. Follow The Joint Commission’s reporting and root-cause analysis requirements, detailed in the organization’s accreditation manual.

While it might feel natural to want to downplay or keep quiet on the event, in the long run, it benefits more people to address the situation directly and honestly. Voluntary reporting can not only improve operations in your hospital but bring to light potential similar situations for your peers as well. You can take the damage from a sentinel event and bring some good out of the situation by making improvements and increasing awareness of similar risks across the industry.

Better Communication and Technology to Report and Address

According to the Institute of Medicine (IOM), medication errors harm 1.5 million people yearly in the U.S. and kill thousands, with an annual cost of at least $3.5 billion. On average, according to The Joint Commission, a hospitalized patient is subject to at least one medication error per day (though error rates vary widely among hospitals). Fortunately, most do not cause serious harm, but those that do can be expensive: each preventable adverse drug event (ADE) costs a hospital approximately $8,750.

However, The Joint Commission also states that at least a quarter of medication-related injuries are preventable, primarily through better communication procedures and technologies. For example, reducing paper records in favor of easily transferrable electronic patient care records (ePCRs) can cut down on data entry errors or lost documentation. All practitioners – from medics to nurses to physicians – can enter notes directly into a single electronic patient record, rather than handing off handwritten notes that must be later entered by another person. Additionally, utilizing “do not use” abbreviation lists and medication reconciliation tools can avoid omissions, duplications, dosing errors, or drug interactions.

More Tools for Reducing Errors

Among the available tools for hospitals, bidirectional software breaks down the communication barriers between all health care professionals treating a patient in the continuum of care. Based off the concept of an easily updateable electronic patient care record that can be shared and accessed in real-time, software like ESO Health Data Exchange (HDE) gives every practitioner a fuller picture of precisely what they are facing and what has already been done, and improves time to treatment.

For example, EMTs can use HDE to include photos, video, and timestamps of patient interactions directly into the patient’s record, from the field. This can be directly imported into the hospital’s system and updated as the patient progresses through intake. Additionally, ESO Alerting tools can further prepare a hospital for an arriving patient, as medics can call for an activation of a CathLab, have a specialized team waiting in the ED, and have hospital staff already up-to-speed on the patient’s condition before they even arrive.

The ability for medics, nurses, and physicians to directly input notes and updates into the patient’s digital record – without having to track down missing paper records or transcribe handwritten notes – not only saves time but reducing human error. The ePCR follows the patient up to discharge and can later be easily accessed for billing or inclusion in hospital operational analytics. And in the unfortunate event of a post-discharge sentinel event – which can happen at times – a well-documented record of the patient’s full treatment is readily available for review and reporting.

Shifting From a Culture of Blame

Experts agree that to continue to drive down the number of sentinel events, the fear and blame mentality must be shifted away from reporting and addressing sentinel events. In fact, most sentinel events are reflective of a wider-scale gap or systemic failure, as opposed to a single practitioner’s error or lack of care.

When organizations are more comfortable honestly reviewing and reporting on sentinel events, without fear of a loss of prestige or embarrassment, errors can be discovered and corrected not only within that hospital but on a broader scale across the industry. This can save not only millions of dollars, but thousands of patient lives.

Learn more about ESO Health Data Exchange software and how it makes communicating patient information easier, more secure, and more reliable.