Causes of Sentinel Events

Communication Failures
Other

Joint Commission on Accreditation of Healthcare Organizations. 2005 National Patient Safety

Goals. Available at: www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/.
 Causes of Sentinel Events

Too Late to Be
Effective
Didn’t Include the
Right People
Included Inaccurate or
Incomplete Info
Purpose was Not
Achieved

Lingard LS, Espin S, Whyte G, et al. Communication failures in the operating room: An observational
classification of recurrent types and effects. Qual Saf Health Care 2004; 13: 330-334.
The Patient’s Role in Promoting Safety
The patient is involved in:
• Helping to reach an accurate diagnosis.
• Deciding an appropriate treatment or management
strategy.
• Choosing a suitably experienced and safe provider.
• Ensuring that treatment is appropriately administered,
monitored, and adhered to.
• Identifying side effects or adverse events quickly and
taking appropriate action.
Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care
2002;11:76–80.
The Patient’s Role in Promoting Safety
The patient is involved in:
• Helping to reach an accurate diagnosis.
• Deciding an appropriate treatment or management
strategy.
• Choosing a suitably experienced and safe provider.
• Ensuring that treatment is appropriately
administered, monitored, and adhered to.
• Identifying side effects or adverse events quickly and
taking appropriate action.
Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care
2002;11:76–80.
The Patient’s Role in Promoting Safety
The patient is involved in:
• Helping to reach an accurate diagnosis.
• Deciding an appropriate treatment or management
strategy.
• Choosing a suitably experienced and safe provider.
• Ensuring that treatment is appropriately
administered, monitored, and adhered to.
• Identifying side effects or adverse events quickly and
taking appropriate action.
Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care
2002;11:76–80.
The Patient’s Role in Promoting Safety
The patient is involved in:
• Helping to reach an accurate diagnosis.
• Deciding an appropriate treatment or management
strategy.
• Choosing a suitably experienced and safe provider.
• Ensuring that treatment is appropriately
administered, monitored, and adhered to.
• Identifying side effects or adverse events quickly and
taking appropriate action.
Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care
2002;11:76–80.
The Patient’s Role in Promoting Safety
The patient is involved in:
• Helping to reach an accurate diagnosis.
• Deciding an appropriate treatment or management
strategy.
• Choosing a suitably experienced and safe provider.
• Ensuring that treatment is appropriately administered,
monitored, and adhered to.
• Identifying side effects or adverse events quickly and
taking appropriate action.
Vincent CA, Coulter A. Patient safety: what about the patient? Qual Saf Health Care
2002;11:76–80.
The top three reasons for hemorrhage
related deaths …
• Provider factors • lack of assessment-resulting in
misdiagnosis-and delayed or
ineffective treatment

• Systems of care factors • related to lack of patient care

coordination and poor
communication between providers

• Patient factors • lack of knowledge of warning signs

and the need to seek care

Building U.S. Capacity to Review and Prevent Maternal Deaths. (2018). Report from nine maternal
mortality review committees. Retrieved from: http://reviewtoaction.org/Report_from_Nine_MMRCs.
25%
High Risk
25%
High Risk
60%
Hemorrhage