When to report sentinel events during transfers

In the past 3½ years, the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has reviewed 20 sentinel events affecting patients in emergency departments, according to Donna Larkin, media relations specialist for the Joint Commission. Twelve were associated with significant and avoidable delays in assessment or treatment of the patients.

A sentinel event is any unexpected occurrence involving death or serious physical or psychological injury. One type of sentinel event that is particularly relevant to ED managers involves the transfer of a patient from one hospital to another following the occurrence of an "error," notes Larkin.

For example, a patient comes to Hospital A and a medical error happens, such as a life-threatening medication error. If the patient is transferred to Hospital B and subsequently dies while being treated in the receiving hospital, this case would be a "reviewable" sentinel event under the Joint Commission’s policy, Larkin explains.

Who is accountable for conducting the root-cause analysis for that sentinel event? "In this situation, where the patient died is not a factor in this determination," she says. "The objective is to understand why the event occurred and how to prevent it. This event is related to a medication error, so the sending hospital would be responsible for performing the root cause analysis."

The receiving hospital was treating a patient with a life-threatening condition (resulting from the medication error), but it was not involved in the error, she says. Therefore this would not be considered a reviewable sentinel event for the receiving hospital unless some other error occurred there that worsened the prognosis of the patient, Larkin explains.