Preventable medical errors endanger patient safety and are too familiar in hospitals worldwide. These errors, the most severe of which are referred to as sentinel events and the less severe as adverse events, are not limited to low-quality organizations; excellent healthcare organizations can and do experience unfavorable events. What distinguishes high-quality organizations from low-quality ones is whether they respond to sentinel and adverse events in a way that significantly reduces the likelihood of the event occurring again. Quality hospitals create a safer patient environment after an adverse event by conducting extensive system analysis, revising processes that cause or contribute to these events, and monitoring the effectiveness of any changes.
Adhering to a sentinel event policy should help healthcare organizations reduce the occurrence of sentinel events and create a culture committed to identifying errors before they occur and being comfortable reporting errors if and when they occur. Every sentinel event policy should be based on a blame-free culture that recognizes that sentinel and adverse events are frequently the results of total system failure rather than individual practitioner failures.
A blame-free culture in the intensive care unit is critical (ICU). Patients in the ICU may be at a higher risk of experiencing a sentinel or adverse event because ICU work is intense, with many interactions occurring between patient and caregiver, and because the nature of critical illness reduces both patients’ natural resilience and their ability to defend themselves from the consequences of human error. According to one study, 54.8% of ICU patients had a severe adverse event during their stay, compared to 38.1% of those who had never been in an ICU (The Joint Commission Guide to Priority Focus Areas, 2004). The Harvard Medical Practice study’s researchers also concluded that patients 65 and older had twice the risk of experiencing an event due to negligence than those between the ages of 16 and 45. (Brennan et al. 1991).
Write 1000 words on how to prevent any future such sentinel events.