Before starting my career as a Texas medical malpractice attorney, I was a hospital administrator. One of my assignments as a hospital leader was to serve as the Joint Commission compliance officer.
The Joint Commission is the major accrediting body for hospitals all over America. Accreditation is big business because hospitals must have it in order to receive Medicare and insurance reimbursements. Needless to say, hospital administrators and leaders pay close attention to the constantly-updated standards and guidelines put out by the Joint Commission.
I learned a lot about patient safety and care by studying the Joint Commission standards. As part of the accreditation process, surveyors came to the hospital to review records, policies, procedures, and other documentation. I had to make sure that our hospital could demonstrate that we followed the Joint Commission standards.
In my experience, the sentinel event standard is one of the most important requirements that hospitals have to master for accreditation. Many people describe sentinel events as “never events,” because they’re serious threats to patient safety that should never occur. More formally, though, the Joint Commission defines a sentinel event as a patient safety event that causes death, permanent harm, severe temporary harm, or intervention required to sustain life.
When sentinel events occur, accreditation standards require hospital committees and leadership to study what happened. This process is called a root cause analysis and is designed to make sure that hospital leaders and healthcare providers learn how to avoid similar future errors.
In 2018, there were 801 reports of sentinel events. The top 10 categories for sentinel events are as follows:
(1) Patient falls: 111 reports
(2) Unintended retention of a foreign body: 111 reports
(3) Wrong-site surgery: 94 reports
(4) Unassigned: 68 reports
(5) unanticipated events including asphyxiation, burns, choking on food, drowning, or being found unresponsive: 59 reports
(6) Suicide: 50 reports
(7) Delay in treatment: 43 reports
(8) Product or device event: 29 reports
(9) Criminal event: 20 reports
(10) Medication error: 24 reports
Based on my experience as a Houston, Texas medical malpractice lawyer, I think it’s highly likely that these numbers are grossly under-reported. For example, in the last year alone, I have handled cases including: (1) a piece of surgical gauze left in a patient after surgery, causing a massive infection and sepsis; (2) a surgical towel left in a patient after surgery, causing a massive infection and sepsis; and (3) a surgeon operating on the wrong patient. On top of that, I’ve investigated countless cases involving delays in treatment caused by nursing and physician errors.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. Also, in 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.