Most Common Causes of Sentinel Events
Human factors are the most common cause of sentinel events in healthcare settings, accounting for approximately 46.5% of all sentinel events. 1
Understanding Sentinel Events
A sentinel event is defined as an unexpected occurrence resulting in death or serious physical or psychological injury, or the risk thereof 2. These events require immediate investigation and response to minimize the risk of recurrence 3.
The Joint Commission's Sentinel Events Evaluation (SEE) study identified several major categories of sentinel events that occur with considerable frequency in healthcare settings:
- Medication errors - The most common type being wrong strength/concentration (34.8%), wrong route of administration (30.7%), and wrong dosage form (30%) 1
- Unplanned dislodgement or inappropriate disconnection of lines, catheters, and drains - Affecting 158 out of 1,913 patients in a 24-hour period 4
- Equipment failure - Observed in 112 patients during the SEE study 4
- Loss, obstruction or leakage of artificial airway - Affecting 47 patients 4
- Inappropriate turn-off of alarms - Observed in 17 patients 4
Root Causes of Sentinel Events
The primary causes of sentinel events include:
Human factors (46.5%) - This includes errors in judgment, technical errors, and failures in following established protocols 1, 5
Miscommunication (35%) - Communication failures between healthcare providers, between providers and patients, or within healthcare teams 1, 5
Name confusion (18.4%) - Particularly relevant in medication errors 1
Inadequate patient assessment - Failure to properly evaluate patients' conditions or risk factors 2
Staffing issues - Including inadequate staffing levels, staff competency problems, and credentialing issues 5
Equipment failures - Including improper use of equipment or defective monitoring systems 5, 4
Lack of continuous observation - Particularly for high-risk patients or those in restraints 5
Risk Factors for Sentinel Events
Several factors increase the likelihood of sentinel events:
- Organ failure - Patients with any organ failure have 1.13 times higher odds of experiencing a sentinel event 4
- Higher intensity level of care - 1.62 times increased odds 4
- Longer exposure time - 1.06 times increased odds per unit of time 4
- High patient-to-nurse ratios - Associated with increased medication errors and nosocomial infections 5
- High unit occupancy rate - Contributes to increased risk of errors 5
Prevention Strategies
To reduce sentinel events, healthcare organizations should implement:
Comprehensive staff training - In proper use of restraints, medication administration, and alternatives to physical restraint 5
Improved communication protocols - Standardized handoffs and communication tools to reduce miscommunication 2, 5
Continuous observation - For all patients in restraints or at high risk 5
Critical incident reporting systems - To identify patterns and implement preventive measures 5
Regular equipment maintenance - To prevent failures of monitoring systems and other critical equipment 5
Pharmacist involvement - Having a pharmacist present in the unit significantly reduces medication errors 5
Root cause analysis - Systematic investigation of sentinel events to identify underlying causes and implement corrective actions 5
Proactive risk assessment - Identifying potential failure points before adverse events occur 3
Reporting and Analysis
The Joint Commission recommends:
- Treating sentinel events as opportunities for improvement rather than occasions for blame 5
- Conducting thorough root-cause analyses to identify systemic issues 5
- Implementing specific, measurable improvements based on findings 3
- Monitoring the effectiveness of implemented changes 2
By addressing these common causes and implementing preventive strategies, healthcare organizations can significantly reduce the occurrence of sentinel events and improve patient safety.