Patient safety is a foundational responsibility of all health care workers. The Joint Commission identifies “sentinel events” related to patient safety and distributes them to Hospitals. During accreditation visits, JCAHO evaluates the Hospital’s effectiveness in addressing, reporting, and eliminating sentinel events.
“A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.” wikipedia
Examples of sentinel event are:
- Infant abduction
- Rape
- Suicide
- Transfusion reaction
- Wrong surgery
- Wrong radiation dose
Recently, the Joint Commission published a Sentinel Event related to the use of opioids in the Hospital. The following points are included in the Sentinel event report:
- Implement effective practices, such as monitoring patients who are receiving opioids on an ongoing basis, use pain management specialists or pharmacists to review pain management plans, and track opioid incidents.
- Use available technology to improve prescribing safety of opioids such as creating alerts for dosing limits, using tall man lettering in electronic ordering systems, using a conversion support system to calculate correct dosages and using patient-controlled analgesia (PCA).
- Provide education and training for clinicians, staff and patients about the safe use of opioids.
- Use standardized tools to screen patients for risk factors such as oversedation and respiratory depression.
By posting the Sentinel event, the Joint Commission has established guidelines for health care workers to follow, including anesthetists. Click here to read the advisory published by the Joint Commission.