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Sentinel events of all types should be treated like crises requiring an immediate and well-rehearsed response, say risk managers who have developed innovative strategies to prepare their facilities. A mock sentinel event can help your staff become comfortable with the tasks necessary to respond in a real crisis, they say, and a sentinel event rapid-response team can ensure you get the most out of an investigation.
The Joint Commission on Accreditation of Healthcare Organizations defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome." Many health care providers interpret that definition broadly, partly because they want to play it safe with the Joint Commission and partly because even a "borderline" sentinel event presents a learning opportunity for risk managers and other staff. Janice Piazza, RN, MSN, MBA, director of advance learning workshops for Berwyn, PA-based VHA East, says a mock sentinel event is an excellent way to test your facility’s response and to spot weak areas before the real thing happens.
"We did this in my previous role at a hospital and it was a great way to assess our readiness," she says. "We did like any other kind of mock scenario or drill at the facility, the same way we would do a mock infant abduction or a mock disaster. We alerted the appropriate staff and said, This just happened. What do you do?’"
Piazza says a mock sentinel event is particularly useful at the leadership level since much of the activity after a sentinel event is there and not on the staff level. The mock sentinel event can help you recognize many questions that otherwise might not occur to you until the real thing happens, she says. Who needs to be notified? Who takes charge of the response? What information is released to the media and how? Who speaks with the patient’s family?
Mock sentinel events should be conducted regularly, just as you conduct disaster drills and other tests for readiness. Piazza offers these suggestions for how to conduct a mock sentinel event:
• Use a variety of scenarios.
You can use any type of incident that would qualify as a sentinel event — a gross clinical error such as cutting off the wrong limb, or a patient suicide. It might be useful to use an event that actually has happened at your facility in the past for the drill. Knowing how you responded in the past — and what you could have done better — will help you focus on certain aspects of the response during the drill.
But be sure to mix it up. Don’t use the same type of scenario all the time or scenarios from the same general topic, such as surgical errors. Your staff might get good at responding to that type of crisis but not be as good at responding to something very different.
• Take advantage of other drills.
Any other in-house drill involving an incident that could be a sentinel event presents the opportunity to test your team’s response. One obvious example is infant abductions. If your hospital conducts infant abduction drills in which the staff practices the procedure for notifying security, establishing a perimeter to watch for the abductor, and so forth, you can ride piggyback on that drill. Follow through after the abduction drill by testing how you would respond to the incident as a sentinel event.
• Warn some, but not everyone.
As with most other types of drills, you probably should warn some key players that a mock sentinel event will be conducted. That will help them head off any unnecessary — and potentially counterproductive — actions, such as actually calling the police department. But for most hospital staff, the mock sentinel event should come as a surprise. Just as the real thing would.
"You have to have a few people know what’s going on so they can role-play the event. They will need to know the scenario so they can inform others what has happened and answer questions that come up," Piazza says. "But for most people, the most they should know is that you’ll conduct a mock sentinel event at some point and they should be ready to respond."
Because a sentinel event response requires the involvement of people in leadership roles, Piazza suggests you consult with administration about picking the day and time. Then you will have to work with the people involved in the scenario you have chosen.
"If you’re doing a surgical event, you need to go to the OR [operating room] and enlist some people to help," she says. "Describe the event, give them the details they need to know about what happened and let them know when the drill will be done. Then they should role play the event when people start investigating it."
• Start from the beginning of the event.
To make the drill as realistic as possible, start the drill from the very moment that you learn of a sentinel event at the hospital. The people involved in the event — the operating room staff, for instance — should call the risk manager to report the incident, or whatever step your policy calls for at that point. That notification should kick off the drill.
Of course, if that phone call doesn’t prompt your staff to respond to a sentinel event, you’ve found your first problem.
• Take the scenario to the point of further investigation.
Try to carry the mock sentinel event as far as you can without actually getting into the entire root-cause analysis (RCA). The key points you are looking for are the way your staff reacts and whether everyone knows their role. Take note of what decisions must be made and who must make them. Are tasks being overlooked? Is evidence lost because it wasn’t collected quickly?
"There’s no end to what you can learn about your response," Piazza says. "Be sure to make it a learning experience in which everyone feels comfortable pointing out ways to make the next one better, and not a punitive situation in which people are just afraid of being tested."
A quick response is the goal of another strategy employed by Sherry Martin, MD, associate vice president for process improvement in the department of quality improvement at the M.D. Anderson Cancer Center at the University of Texas. Martin and her colleagues at the hospital realized that a speedy response to sentinel events, or even near sentinel events, could serve two purposes. First, the hospital could gather more and better information if it was gathered quickly. And second, staff were more likely to report incidents if they knew the administration would respond promptly.
"We’ve always encouraged people to let us do a sentinel event analysis on the near misses, to reach for the low hanging fruit in addition to the situations where the sentinel event is obvious. There’s a lot we can learn from those near misses," Martin says. "Well, our phone never rang. When we asked why, they said it takes too long and it was too long before any improvements were implemented."
So M.D. Anderson organized what it calls the Rapid Response RCA. Under this plan, anyone can call Martin’s office and report a near miss, or even a situation that just has the potential for leading to a sentinel event, and Martin promises that quality improvement and risk management staff will respond within one hour.
"We’ll get there within the hour, and then we’ll do a one-hour root-cause analysis, a quick version of what we normally do," she says. "We promise we’ll be there right away so people don’t have to wait around and take a lot of time out of their day. That was a big deterrent. And it’s also good for us because we get good information right after the event or while the thought is still fresh in people’s minds."
The one-hour analysis might lead to a complete, full-scale RCA if necessary. And if the incident qualifies as a sentinel event, the rapid response might be only the first step in a complete sentinel event response. But Martin says the rapid response is used for many situations that never would have been reported because they didn’t reach the level of a sentinel event. Recent examples include a unit that missed necessary blood draws twice in one month, and clinicians who complained that the arrangement of telephones made it difficult to receive calls during rounds.
"People see the rapid response almost as a problem-solving opportunity and that’s good because everyone benefits," she says. "We get to head off problems that could snowball into something serious and they can solve a problem that’s been bothering them. It’s good when we get there right away, after people spent the morning complaining or worrying about something and decided to call us. It’s still on their minds and we get a clear understanding."
The rapid analysis might determine that more information is needed, so the team can establish a quick data collection system, with the emphasis on keeping it simple. If the team needs to know how often something happens in a certain unit, for instance, it might give the nurses a sheet of colored stickers and ask them to just put one on the patient’s chart when the problem occurs.
"The idea is to be proactive, to handle these relatively minor problems before they lead to a serious adverse event and you have to go into a complete RCA," she says. "Then you’re obligated to do a lot of work that requires so many people to drop whatever they’re doing. And that process is punitive, no matter how hard we try, so we like to avoid that when possible."
Once the problem is identified, Martin and her staff make it a priority to provide a solution as quickly as possible. When the intensive care unit found that requested blood draws were not always performed, the rapid analysis determined that the way the requests were entered in the computer system did not always indicate to the phlebotomists that the ICU requests were high priority. The solution was to provide pagers to the phlebotomists so that the ICU staff could summon them directly.
For the phone problem, Martin had the phone system in that unit redesigned so that physicians could receive calls while caring for patients. And it was changed quickly.
"That’s what matters," Martin says. "When the staff sees something happen that makes their life easier in pretty quick order, they’re encouraged. They know it’s worth their time. Now the phone rings all the time."