Sentinel events are broadly defined as preventable medical errors that seriously harm patients. They also are called “never events” because their potential consequences are so grave they should never happen. A prominent healthcare safety organization has identified the top sentinel events occurring last year.
The Joint Commission’s mission is to continually improve public healthcare. Part of its role is accrediting U.S. hospitals. It recently published a report that listed the top 10 sentinel events of 2021 – most of which occurred in hospitals.
The Joint Commission began publishing the list in 2007. The 2021 list includes the highest number of sentinel events ever tabulated in one year. The report shows that between January 2002 and December 2021, nearly 90% of all sentinel events happened in hospitals.
The organization further defines sentinel events as preventable medical errors that result in:
· Death of the patient
· Permanent harm to the patient
· Severe temporary patient harm that requires medical intervention to save the patient’s life
Causes of Preventable Patient Falls That Result in Serious Injury
The most common sentinel event in 2021, according to the report, was a patient fall. Hospital patient falls are common. The Agency for Healthcare Research and Quality estimates as many as 1 million hospital patients fall every year.
The Joint Commission classifies those patient falls as sentinel events that result in death or other permanent harm, as well as surgery, fractures and serious internal injuries.
Patient falls that cause these catastrophic injuries are highly preventable. The report identifies several contributing factors leading to patient falls, including:
· Communication failures
· Inadequate patient assessments
· Inadequate staffing levels or staffing supervision
Surgical errors are among the most serious medical errors. One type of surgical error – retention of a foreign object in the patient’s body – is high on the list of 2021’s most common sentinel events.
The report notes objects left behind in surgical patients’ bodies include:
· Surgical instruments
· Catheters and drains
‘Wrong Surgery’ Errors
Another type of serious surgical error is also on the list. “Wrong surgery” is a potentially catastrophic medical error that encompasses:
· Operating on the wrong patient
· Operating on the wrong site of the patient
· Performing the wrong procedure on a patient
The Joint Commission identifies the main causes of wrong surgery errors. They include errors during the scheduling of the surgery; inadequate patient verification prior to surgery; communication errors in the operating room; and an ineffective organizational patient safety culture.
Suicides, according to The Joint Commission, are sentinel events when they occur while a patient is receiving treatment in a 24-hour staffed medical facility or within 72 hours of leaving the facility.
The report notes three steps medical facilities should take to prevent patient suicides:
· Assess and minimize environmental risks
· Screen patients for suicide risk
· Adhere to counseling policies and appropriate follow-up for patients deemed at risk for suicide
Delay in Treatment Medical Error
Medical misdiagnoses can be catastrophic. A wrong diagnosis, a missed diagnosis, or a delayed diagnosis can lead to another frequent patient sentinel event in 2021: delay in treatment.
The Joint Commission’s causes for a delay in medical treatment, in addition to misdiagnosis, range from mistakes made by individuals to system-wide failures. Inadequate patient assessments, poor communication, understaffing and poor scheduling systems are among the causes for a potentially serious delay in medical treatment, according to the organization.
That so many sentinel events occur and so many patients are catastrophically injured every year is troubling. Even more troubling is that these medical mistakes and resulting patient deaths and severe injuries are preventable.
If you suspect you or a loved one was the victim of a serious medical error, turn to a medical malpractice lawyer to investigate on your behalf.
The choice of a lawyer is an important decision that should not be based solely on advertisements.
Authored by Gray Ritter Graham, posted in Articles March 30, 2022