What are hospital sentinel events?
Some things are so dangerous to patient safety that hospital accreditation standards say that they should never happen
The Joint Commission is the oldest and best-known organization that accredits hospitals. In 1996, it adopted a formal policy to require hospitals to learn from serious events that may be related to patient safety. The Joint Commission calls this the Sentinel Event Policy, with the idea that a sentinel event is so serious that they require immediate investigation and response.
By definition, a sentinel event is a patient safety event that reaches a patient, resulting in death, permanent harm, or severe temporary harm and intervention required to sustain life.
As a former hospital administrator, I recognize the importance of a hospital culture that investigates and learns from patient safety incidents, rather than one that sweeps them under the rug. Adding that experience to what I have seen as a Houston, Texas medical malpractice attorney, I realize that some hospitals do a better job than others.
Memorial Hermann and hyponatremia
The topic of sentinel events reminds me of two incidents that happened several years ago.
In the first incident, I represented the family of a teenager who was treated at Children’s Memorial Hermann Hospital. She was a bright, athletic student who had a sinus infection that spread to her brain and formed an abscess. Of course, that abscess needed addressed, and the surgical team at the hospital did a great job in draining it. The family recalls being assured that after a number of weeks of antibiotic treatment, the young lady would be on her way back to school and a normal life.
Unfortunately, this teenager ended up with a severe brain injury, and I filed a medical malpractice lawsuit on behalf of her family in order to get funds to take care of her.
In the course of the lawsuit, we retained an internal medicine physician as an expert witness on the issue of hyponatremia, a condition in which a patient has abnormally low serum sodium levels. Hyponatremia inexpensive to treat, but requires careful attention from nurses and physicians.
The expert explained that any patient with a head trauma or space-occupying lesion within the cranial cavity has a particularly-high risk of developing hyponatremia. Left untreated, the brain will swell and swell until it herniates out the back of the skull, causing death. In this case, the diagnosis of hyponatremia was so delayed that the patient had an impending brain herniation before treatment started. She survived, but with a severe brain injury.
Within six months of the resolution of the case, a friend from church called to discuss his adult son’s recent car wreck. The conversation started with his questions about how the auto insurance policies would work. Over the course of our discussion, I learned that his son had experienced a head trauma, including brain hemorrhaging, and had been in the hospital for two weeks at Memorial Hermann Hospital in the Texas Medical Center.
As I always do, I recommended that a family member should stay with his son 24/7 until he was safely discharged. I then told him that, while I did not want to disturb him, I wanted to tell him the story about what happened to another patient at the Memorial Hermann facility next door, under somewhat similar circumstances. I then told him about the first case that I wrote about above.
One additional fact was that a key finding in the first case was that the teenaged patient began acting strangely. Her parents described it as acting out of character. Medical professionals describe it as altered mental status. Our expert witness explained that altered mental status is one of the earliest indicators that there could be a neurological problem requiring urgent physician attention.
Although I felt that it would unlikely happen, I told my friend that of his son started acting out of character, he should immediately tell the nursing staff. After all, family member will always know when a relative is behaving abnormally more quickly than a healthcare provider could notice. I suggested that, if this happened, he should ask the nursing staff when his son’s serum sodium level had last been checked, and if it had been more than a day, to firmly request that they get in order to re-check it.
About a month later, my friend called and told me that within 48 hours of our initial conversation, he noticed that his son was behaving oddly. He asked the nurse about his last serum sodium level and she said it was from two days before, but everything was fine. He insisted that she call the doctor to get an order for blood work. According to my friend, they did the blood work, and it was not long before lots of doctors and nurses rushed to his room to start emergency treatment of his hyponatremia.
I called the expert witness from the first case and told him this story, and he asked what the man’s serum sodium level was. When I told him, the expert asked when he had died. The expert was shocked to learn that the man had fully recovered.
Within a few months, I saw one of the Memorial Hermann administrators in charge of risk management, at a deposition in another case. I told her about the two stories and how I really believe that it is important for hospitals to learn from patient safety events. She agreed and said that she would investigate it. I really hope that they got their nurses and physicians on their medical staff to take some corrective actions that would prevent things like this from happening again.
The Joint Commissions sentinel event areas
As I mentioned above, The Joint Commission currently considers any patient event resulting in death, permanent harm, and severe temporary harm to be a sentinel event. In addition, though, the following situations also are considered sentinel events:
· Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the hospital’s emergency room.
· Unanticipated death of a full-term infant.
· Discharge of an infant to the wrong family.
· Abduction of any patient receiving care, treatment, and services.
· Any unauthorized departure of the patient from a staffed around-the-clock care setting, including the emergency room, leading to death, permanent harm, or severe temporary harm to the patient.
· Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities.
· Rape, assault, or homicide of any patient receiving care, treatment, and services (or a staff member, licensed independent practitioner, visitor, or vendor) while on site at the hospital.
· Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure.
· Severe neonatal hyperbilirubinemia.
· Prolonged fluoroscopy or any delivery of radiotherapy to the wrong body region or over 25% above the planned radiotherapy dose.
· Fire, flame, or unanticipated smoke, heat, or flashes occurring during episode of patient care.
· Any maternal death related to the birth process (intrapartum).
· Severe maternal morbidity resulting in permanent harm or severe temporary harm. Severe maternal morbidity is anything that occurs from the intrapartum through the immediate postpartum period (24 hours), requiring the transfusion of four or more units of packed red blood cells (PRBC) and/or admission to the intensive care unit (ICU).
The Joint Commission requires accredited hospitals to review all sentinel events, including:
· A formal team response that stabilizes the patient, discloses the event to the patient and family, and provide support for the family as well as staff involved in the event.
· The hospital leadership must be notified.
· The hospital must institute an immediate investigation.
· The hospital must use a comprehensive systematic analysis to identify the causal and contributory factors of the sentinel event.
· The hospital must implement strong corrective actions to result in sustainable improvement over time.
· There must be a time line for implementation of corrective actions.
· There must be demonstrated systemic improvement.
We are here to help
If you or someone you care for has been seriously injured as a result of poor hospital care, call the experienced medical negligence lawyers at Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.
Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He has experience in representing patients and their families in medical negligence and wrongful death lawsuits against doctors, surgeons, anesthesiologist, and hospitals, like those in the Memorial Hermann, Houston Methodist, and CHI St. Luke’s systems.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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