What is a medical error or sentinel event?

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    Medical errors can be prevented

  • According to the Institute of Medicine study, To Err is Human, between 44,000 and 98,000 Americans die each year from preventable medical mistakes they experience during hospitalizations.
  • The most common medical errors include:
    • Adverse drug events
    • Improper blood transfusions
    • Surgical injuries
    • Wrong-site surgery
    • Patient suicides
    • Restraint-related injuries or death
    • Patient falls
    • Patient burns
    • Infant abduction
    • Patient elopment
    • Mistaken patient identities
  • The Joint Commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, ‘or risk thereof’ includes any process variation for which a recurrence carries a significant chance of a serious adverse outcome.” Such events are called "sentinel" because they signal the need for immediate investigation and response.
  • While death is the most tragic outcome, preventable medical mistakes cause other problems as well. Based upon the findings of a study of two prestigious teaching hospitals, almost 2 percent of hospital admissions experience a preventable medication error, resulting in an average increased hospital cost of $4,700 per admission or about $0.5 million annually per 100 beds.
  • The real tragedy is that most of these medical mistakes are preventable. They are most often caused by systems that break down and don't support the highly qualified and dedicated hospital caregivers the way they should.
  • While significant and attracting attention, medication errors aren’t the only types of medical errors that hospitals need to pay attention to. Based upon a review of over 1,900 sentinel events reviewed by the Joint Commission since January 1995:

    • Patient suicide accounted for 16.5% of the errors
    • Operative/post-operative complication – 12.3%
    • Wrong-site surgery – 11.7
    • Medication error – 11.5

     

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