A sentinel event is an event that has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition. In other words, it is an unexpected incident. One of the best ways to understand a sentinel event is to look at examples of what are and are not sentinel events. Some of the examples of a sentinel event include: any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error, any suicide of a patient in a setting where there is around-the-clock care, any procedure on the wrong patient, any intrapartum maternal death, a patient fall that results in death or major loss of function as a direct result of the injuries sustained in the fall, and a hemolytic blood transfusion reaction involving major blood group incompatibilities. Examples of non-sentinel events are: any "near miss," return of full limb or bodily function to the same level as prior to the adverse event by discharge or two weeks after the initial loss, any sentinel event that has not affected a recipient of care patient, resident, client , medication errors that do not result in death or major loss of function, unsuccessful suicide attempts, retained foreign bodies without major loss of function, or minor degree of hemolysis with no clinical sequelae. An ED nurse should check to see if the facility has a policy and procedure on what to do if a sentinel event occurs.
JCAHO's sentinel event policy: What every ED nurse should know
Two Wrongs Don't Make a Right (Kidney) | PSNet
Based on this assessment. What is the most accurate assessment if the client believes that the healthcare providers are FBI agents and that there are cameras in his apartment to monitor his moves? Which behavior is characteristic of a thought disorder? The nurse understands that schizophrenia can be differentiated from psychosis by which assessment? Which finding depicts negative symptoms of schizophrenia? Which nursing problem has priority?
A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event. The Joint Commission works closely with its organizations to address sentinel events and to prevent these types of events from occurring in the first place. View the full list of Sentinel Event Alert publications.
In July, a teenage mother-to-be entered a Madison, Wis. Within hours she was dead, though her baby survived. An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure.