What is a Sentinel Event?

Any event resulting in permanent harm, severe or temporary harm, or death to a patient is defined as a sentinel event by The Joint Commission. These events are incapacitating not only to the patient but to the health care providers responsible for a patient’s well-being. The term sentinel is used to identify an issue within a system that may lead to similar future events.

Suffering a sentinel event while under the care of Oregon medical providers can leave a patient or their family unsure of where to turn for help. Determining whether a sentinel event results from negligence is the first step to getting help from a Portland medical malpractice lawyer.

Classifying Sentinel Events

While sentinel events are devastating, they do not always represent medical negligence or a deviation from the standard of care. Serious reportable events are those identified by the National Quality Forum as those that should never have occurred in a healthcare setting and are recognized as serious, preventable, and creating unambiguous adverse issues. Initially, sentinel events were only those affecting patients, but the definition was later updated to include staff, visitors, and vendors on the premises of a healthcare facility.

The following categories have been established to classify serious reportable events:

• Care management
• Criminal events
• Device/product
• Environmental
• Patient protection
• Radiologic events
• Surgical

Accredited healthcare facilities are responsible for establishing protocols for managing sentinel events.

Examples of Sentinel Events

Sentinel events in a healthcare setting may also be referred to as never events or medical events that should never occur. Examples may include:

• Abduction from a facility while receiving care
• Foreign objects left in the body after surgery
• The wrong body part or person being operated on
• Sexual assault
• Unexpected death of an infant during care
• Death or severe injury of a patient associated with a fall while receiving care
• A patient’s death or serious injury resulting from the use of restraints

Healthcare facilities should have sentinel event policies in place to provide a thorough investigation of the event, an analysis of what took place, and the development of preventive strategies to correct the actions leading to a sentinel event.

Most Commonly Reported Sentinel Events

Recent annual data notes that 88% of voluntary self-reported sentinel events occurred in a hospital setting. Of these reported incidents, the following sentinel events more frequently occurred:

• Patient falls: 42%
• Delay in treatment: 6%
• Unintended foreign object retention: 6%
• Wrong surgery: 6%
• Suicide: 5%

Of these reported events, 20% attributed to a patient’s death. Severe temporary harm was caused to 44% of patients. Sentinel events that led to additional care or extended stays in a care facility were 13%.

Growing Concern Over Sentinel Events

While the number of sentinel events has fluctuated slightly over ten years, the above-cited annual data reveals a 78% increase in sentinel events over a recent two-year period (pg. 4 graph). Accredited healthcare facilities voluntarily reported the majority of sentinel events. However, other unreported events were communicated by the patient, their families, employees, or current employees of the healthcare facility.

Speak with an Oregon medical malpractice attorney if you or someone you care for has been impacted by a sentinel event leading to death, severe temporary harm, or permanent harm.