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Sentinel Events: How is Your Organization Performing?

Becker's Review just released the 10 most common sentinel events according to The Joint Commission:

1. Unintended Retention of a foreign body- 116 2. Fall — 114 3. Wrong-patient, wrong-site, wrong-procedure — 95 4. Suicide — 89 5. Delay in treatment — 66 6. Other unanticipated event, such as asphyxiation, burn, choking on food, drowning or being found unresponsive — 60 7. Criminal event — 37 8. Medication error — 32 9. Operative/postoperative complication — 19 10. Self-inflicted injury — 18

It is disturbing that operating room related events account for 3/10 on the list. This is an area where a significant amount of work has been done to reduce medical errors. This clearly tells me that there are important safety steps being missed, or not happening at all in perioperative services, and likely in post surgical departments.

The TeamSTEPPS program was developed to support effective communication and teamwork in health care. Teamwork has been found to be one of the key initiatives within patient safety that can transform the culture within health care. Patient safety experts agree that communication and other teamwork skills are essential to the delivery of quality health care and to preventing and mitigating medical errors and patient injury and harm.

If you do not have a TeamSTEPPS program in place or staff trained in this program, start by initiating briefings at the start of the day with the lead surgeon or anesthesiologist and the operative team. Discuss important elements to operations for the day, such as resources, flow, types of cases and any high risk issues; ensure that the plan will support the provision for patient care and allow for team members to share feedback.

Before each case, ensure there is a time out and that the critical elements during a time out are discussed with all team members involved in the OR. Encourage staff to speak up if they feel there is a potential safety issue. TeamSTEPPS provides the necessary communication tools to help staff speak up.

After each case, prior to leaving the operative suite there should be a team debriefing over the case; what went well and what opportunities may have existed. Ensure all counts are completed to avoid a retained sponge or device, and assign someone to do a sweep of the OR prior to leaving the room. The procedures noted should be documented and reviewed for continuous quality improvement. Results should be shared and discussed with the teams involved, with appropriate action plans in place to improve. Assigning unit based champions (including a physician and nurse) can improve the teams engagement and empowerment to keep their patients safe.

The importance of huddles, checks, double checks, time outs, briefings and debriefings are critical to supporting staff and protecting patients. Use of communication tools (ex. SBAR) from the surgical suite to the inpatient unit or recovery room are also important to ensure continuity of care and to identify any potential risk. It is also important to celebrate a "good catch" when a staff member speaks up for patient safety. Please don't diminish the opportunity to celebrate a good catch and recognize someone; this will encourage a culture of safety.

Match Healthcare Design and Innovation experts provide TeamSTEPPS training that includes onsite assessments, implementation plans, and evaluation. We will work with your team to apply interventions that are sustainable to enhance performance and avoid sentinel events. Take the next step to ensure safety in your facility by contacting us at

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