Learning from sentinel event statistics

AORN Journal,  August, 2004  by Suzanne C. Beyea

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A retired perioperative nurse in her early 80s has been known to make the statement, "If I get sick, don't let me go to the hospital. Hospitals are terrible places. People get sicker and die there." Her friends view her as witty and insightful, but her colleagues, who are concerned about patient safety, find wisdom in her words. For some patients, hospitals are dangerous places. Each day, patients are injured in hospitals, and some of those injuries result in serious adverse outcomes or death.

SENTINEL EVENT STATISTICS

The most recent Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) sentinel event statistics emphasize the potential seriousness of being hospitalized. Since the inception of the sentinel event program at JCAHO in January 1995, more than 2,455 sentinel events affecting 2,570 patients have been submitted and reviewed. (1) Of those occurrences, 75% (n = 1,935) resulted in death, and the remainder resulted in loss of function or other injuries. (1)

These alarming data suggest that serious problems exist in hospitals and other health care facilities, but the sentinel event statistics posted on JCAHO's web site may go unnoticed by many perioperative clinicians. In fact, most busy clinicians focus on day-to-day operations and clinical events. Perioperative clinicians might be aware of a previous wrong site surgery in their facility, but many will remark, "We had a wrong site surgery a few years ago, but we changed our policy and have not had a problem since." Those same clinicians may be aware that their department has experienced a wrong site surgery approximately once every three or four years or one wrong site surgery for every 50,000 surgeries performed. In other words, things go right 99.99% of the time.

When errors occur very infrequently, overall performance rates appear to be excellent. If a wrong site surgery occurs to you, the patient, or you, the nurse, however, that percentage simply is not good enough. No one likes to make an error, nor does anyone want to be the victim of or witness to that error. In perioperative settings, significant errors occur so rarely that most clinicians believe the ultimate fix has been implemented--until the next unanticipated error occurs, often many years later.

If one considers the number of errors reported to JCAHO, it could incorrectly be assumed that 50% of more than 5,000 to 6,000 hospitals in the United States have experienced a sentinel event in the past nine years. In fact, not all sentinel events are reported to JCAHO. The sentinel event program promotes voluntary reporting, which results in underrepresentation of certain types of events. (2) The true scope of sentinel events, therefore, is unknown.

SENTINEL EVENTS IN THE OR

About 65% (n = 1,587) of all reported events occur in general hospitals. (1) For perioperative clinicians, a number of reported events should be of interest. These include intraoperative and postoperative complications, wrong site surgery, medication errors, delays in treatment, transfusion errors, perinatal death or loss of function, fire, ventilator death or injury, anesthesia-related events, infection-related events, and medical equipment-related events. These types of errors combined account for more than 50% of reported sentinel events. (1) The direct relationship of these errors to perioperative settings is unknown, but any of these errors can occur in perioperative settings, and wrong site surgery and anesthesia-related events are specific to the OR.

INCREASED REPORTING

When the sentinel event program began, the majority of sentinel events were identified from media reports, complaints, and survey visits or by the Center for Medicare and Medicaid Services or individual states. In subsequent years, JCAHO has received an increasing number of sentinel events categorized as "self-reported" (ie, submitted by a health care organization). (1)

The increase in reports does not mean that more errors are occurring; it means that more organizations are reporting adverse events and outcomes. This change demonstrates that health care organizations are taking a leadership role in reporting errors and adverse events. It also reflects a shift toward a nonpunitive reporting structure in many health care facilities and a desire to learn from health care errors.

The JCAHO sentinel event program supports organizations' efforts to examine errors in aggregate, consider contributing factors, and make recommendations to prevent subsequent errors. In addition to maintaining statistics, JCAHO also regularly releases Sentinel Event Alerts related to specific sentinel events. These alerts reflect an analysis of root causes related to a specific error and provide various strategies to reduce subsequent errors.

USING THE STATISTICS

Perioperative clinicians are not and cannot be perfect performers every day. Clinicians strive to provide the highest quality care possible and protect patients from harm, but they work with and among systems that inadvertently can contribute to an error. For example, the wrong blood or medication can be sent to the OR, or patients with the same or similar names may be scheduled for surgery on the same day. Each of these situations could lead to an error, especially if a clinician is less than perfect for just a single moment.