Quality & Patient Safety

The cultural cure to sentinel events

Briefings on Accreditation and Quality, May 1, 2016

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The Joint Commission released its 2015 Sentinel Event Statistics in March; based on 936 reported events, the accreditor found the most common sentinel events were unintended retention of a foreign body (116), wrong-site/wrong-side/wrong-procedure surgery (111), falls resulting in death or permanent loss of function (95), and patient suicides (95). The most common root causes for these events were human factors (999), leadership failures (849), communication failures (744), patient assessment (545), and physical environment (202).

Joe Kiani, founder of the Patient Safety Movement Foundation and chair and CEO of the Masimo Corporation, discusses what the statistics mean for patient health and the steps facilities should take in response.

BOAQ: What is the big takeaway from The Joint Commission's sentinel event statistics for 2015?

Kiani: Surprising and disturbing! It is truly amazing that the sentinel event list is topped by "retained foreign body" and "wrong-patient/side procedure." This is on the same level as forgetting to lower the flaps before takeoff in an MD-80 [commercial jet], which has happened twice - both times with fatal results. [The] aviation [industry] responded with procedures that should prevent that event from ever happening again - yet we are still leaving sponges in the abdomen and operating on the wrong side with apparent regularity. I know of a case where a patient had a malignant tumor in one kidney and the other kidney was normal. Surgeons removed the wrong kidney - the normal one. The fact that fires even made the list [10th most reported event in 2015 with 23] is also disturbing.

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