NURSING SENTINEL EVENTS FULL

Under the new definition of ‘Fire’ the following would and would NOT be considered a sentinel event. This includes any fire in the patient’s home that is related to the care or treatment ordered by a provider, including home oxygen administration, as part of the home care services, regardless of whether a home care staff member was present. The new definition of ‘Fire that pertains to home care setting is:įire, flame or unanticipated smoke, heat, or flashes occurring during an episode of patient care. To be considered a sentinel event, equipment must be used at the time of the event and staff do not need to be present.” The new definition, which applies to ambulatory health care, behavioral healthcare, critical access hospital, laboratory, nursing center and office-based surgery is:įire, flame or unanticipated smoke, heat, or flashes occurring during direct patient care caused by equipment operated and used by the organization. Given the safety risks that exist with home oxygen therapy, this is a significant concern.

NURSING SENTINEL EVENTS FULL

The definition did not define the full scope of the home health encounter (which is the entire length of services ordered by a physician).

Another area of concern is that the current definition did not include clinical equipment that malfunctioned when a caregiver was not present in the room.

When the Office of Quality and Patient Safety (OQPS) reviewed the reported events, it was clear that healthcare organizations were experiencing fires or unanticipated smoke, heat, or flashes “in other care locations causing confusion on whether these events should be considered ‘sentinel.’”.The current definition is fire, flame or unanticipated smoke, heat, or flashes occurring during an episode of patient care-was intended to refer to fires in the OR.

Let’s look closer at the current and revised definitions of these three events and some examples of what would and would not be considered a sentinel event under these definitions.

Invasive Procedure (as referred to in relation to wrong-site procedures and unintended retentions).The revisions are effective on January 1, 2020. The Joint Commission adopted the formal Sentinel Event Policy in 1996 “to help hospitals that experience serious adverse events improve safety and learn from those sentinel events.” TJC goes on to define sentinel events as “a Patient Safety Event that reaches a patient and results in…death, permanent harm, or severe temporary harm and intervention required to sustain life.”The Joint Commission has recently announced revised definitions of three terms, in an effort to better clarify and identify sentinel events.

Nursing sentinel events