April 21, 2000
Sentinel Event Alert was first published in February 1998 to provide important information relating to the occurrence and management of sentinel events in Joint Commission accredited health care organizations and, most importantly, information about sentinel event prevention. The information is primarily intended to assist health care organizations reduce the frequency of medical errors and other adverse events.
Data reported by accredited organizations indicate that progress has been made in reducing the relative frequency of selected adverse events. A great deal has been learned from health care organizations' root cause analyses and risk-reduction strategies as well as from experts' recommendations for future prevention. An analysis of the sentinel event information reported to the Joint Commission indicates that the relative percentage of some types of sentinel events that have been the subject of articles in Sentinel Event Alert has decreased since the publication of these related issues. In other cases, the publication of articles has not significantly impacted the relative percentage of types of events being reviewed.
Seeing Results
The Joint Commission began tracking sentinel events in 1995. Through the end of 1999, the Joint Commission has reviewed 709 cases. For each of the events reviewed, a root cause analysis was completed. There were 23 sentinel events reported in 1995, 34 in 1996, 139 in 1997, 180 in 1998 and 333 in 1999. As of May 18, 2000, 161 events have been reported this year.
In this issue, there are five tables that illustrate the percentages of sentinel events reported in a specific area in relation to all sentinel events reported to the Joint Commission for the period 1995 through 1999. There has been a decrease in the relative frequency of sentinel events reported on potassium chloride deaths since the issuance of the February 1998 Sentinel Event Alert on this issue. Similarly, a decline in relative frequencies has been observed for restraint deaths (November 1998 issue), inpatient suicides (November 1998 issue) and infant abductions (April 1999 issue). For other topics, such as wrong site surgery, no significant relative decrease was observed. Topics such as blood transfusions and operative/post-operative complications were covered in issues in 1999 and 2000, so post-publication data are not yet available.
The issue of Sentinel Event Alert that made the largest impact regarded the appropriate storage and handling of concentrated, injectable potassium chloride (KCl), a substance that is deadly when given intravenously in concentrated form and is easily mistaken for more benign substances. In analyzing the causes of KCl-related deaths, it became evident that storage of concentrated KCl on general nursing units was an important cause of unanticipated deaths. The Sentinel Event Alert suggested that storage of concentrated KCl be limited to hospital pharmacies to the extent possible. Since that time, the number of reported deaths has dropped from 12 in 1997 to only one in 1998 and one in 1999.
When interpreting the results presented in this issue, please recognize that the data most likely represent only a small fraction of the total number of such events actually occurring in health care organizations. While the conclusions may not yet meet tests of statistical validity, they support the assertion that sharing "lessons learned" from the review of sentinel events can lead to a reduction in the incidence of those types of events. The Joint Commission will continue to examine the impact that other issues of Sentinel Event Alert have on the incidence of adverse events.
Alerts Offer Suggestions for Improvement
In issues of Sentinel Event Alert, health care organizations, the Joint Commission and various experts have provided recommendations on how other health care organizations can prevent the adverse events from happening in the future. The emphasis has been on "recommendations," but some readers have interpreted these suggestions as being Joint Commission requirements. That was never the intention. These suggestions should be considered for implementation, but if not appropriate for the individual health care organization, alternatives should be considered. The Joint Commission recognizes that other acceptable practices or approaches exist.