Sentinel Events
Various unexpected medical events occur in every healthcare organization, and these occurrences are usually referred to as sentinel events (Watson, 2009). The severity of these events ranges from impacting patients with serious physical and psychological injuries to putting them at a risk of getting serious injuries or the possibility of dying. Majority of these events occur in general hospitals where a number of services are provided to a variety of patients who have different needs with emergency departments experiencing a limited number of sentinel events. Examples of some of the distinct types of sentinel events that frequently occur in a healthcare organization include patient suicide and delay in treatment.
Patient suicide is a common occurrence among psychiatric patients, with the probability of occurrence ranging between 0.5 and 0.7 (Foley and Kelly, 2007). According to studies, patient suicide is common among psychiatric patients in general hospitals than in specialized hospitals, and these patients usually have a record of previous attempted suicides. Other demographic factors that are synonymous with patient suicide in the psychiatric ward include violet behavior, depressive disorders and gender, with males being more prevalent (Chen, Tzeng and Lin, 2012). In psychiatric hospitals, most patients commit suicide by hanging in bathrooms, closets or bedrooms (Knoll, 2012). For this reason, privacy is discouraged in such organizations.
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However, patient suicide is not confined to psychiatric patients since other patients suffering from terminal diseases such as cancer may have and act on their suicidal thoughts. These patients may commit suicide because of a number of factors such as uncontrollable pain, depression due to awareness of the fact that they have a few days to live, refusal to depend on others and possibility of physical impairment and eventual suffering. Such patients have been known to take drug overdoses or may even opt to hang themselves in places such as bathrooms.
On the other hand, delay in treatment occurs when a patient does not receive the stipulated medical care with the inclusion of laboratory tests and physical therapy treatment, within the timeframe that the treatment was supposed to be delivered (Watson, 2009). Delays occur due to the presence of many patients within an organization and this reduces the efficiency of the organization since it reports poor health outcomes. The distinctiveness of this sentinel event arises from the fact that most treatments are usually sensitive to time, making them very critical. Cardiac, surgical and certain emergency needs are critical and hence require punctuality of provision of treatment as a way of reducing the prevalence of death. For example, patients about to undergo a surgical operation need to be given antibiotics within a time frame of between 30 min to one hour before an incision is made on their body so as to prevent the occurrence of an infection after the surgery. Failure to observe this time limit results in infection that may increase the probability of death of the patient after surgery.
Delay in treatment occurs due to a number of contributing factors. One of the major contributing factors is poor communication between the patients, the hospital management and hospital staff, and the community in general. This inhibits the efficient follow-up of care of patients with their physicians, and thus exposes the patient to serious injury or possibility of death, depending on the criticality of the illness. Another contributing factor is low level of professionalism among staff members, resulting in reduced punctuality. A final factor is the unavailability of enough staff members, resulting in distracted, tired or overworked healthcare providers. These factors reduce the efficiency of the staff, especially when the organization has many patients that need to be attended to.
System Factors
A number of system factors influence the organization performance of healthcare organizations. These factors are useful in ensuring that sentinel events are either reduced or avoided within the healthcare organization to ensure that serious injuries and deaths are minimized by reducing the probability of occurrence of these sentinel events and identifying the response techniques that are important for the safety of patients (CPSI, N.d.). These factors include policies and legislations, processes in the organization, resources, workplace culture and people involved. Most of these factors can be overseen by the management who control the implementation of different processes and procedures and the distribution of different resources such as medical equipment, financial and human resources within the organization (Kim et al., 2015). Generally, the management has the duty to maintain the system factors and assess these systems in order to promote patient safety. As a result the management oversees governance, professional requirements and competency of staff, risk management and quality improvement within the organization.
In looking at how system factors influence the performance of an organization, it is important to establish a relationship between these factors and patients safety and evaluate their effectiveness. Policies and legislation govern the daily operations that take place within a healthcare organization (CPSI, N.d.). The legislation provide a standardized method of dealing with certain issues that could lead to sentinel events in order to minimize them. Policies also help to improve efficiency, thus deal with the issue of delay in treatment. The focus on ensuring productivity also ensures that medical organizations deal with any events that could result in patient suicide such as ensuring that psychiatric patients are placed in public wards for easy monitoring and to reduce chances of suicidal attempts. Policies ensure that there is efficient and effective communication among the staff and also make sure that every staff member understands their roles and responsibilities.
Processes in the organization also determine how to carry out different operations by providing clarity (CPSI, N.d.). The provision of treatment abides by certain rules set by an organization, and these determine how effective the provision of medical care is. Having less complicated procedures reduce time spent in implementing one procedure, especially if an organization has a shortage of medical staff (Tarzimoghadam and Zakerian, 2015). As a result, this ensures that the available staff can easily attend to patients. An example is when recording patient information and treatment required. Short procedures that are less complicated ensure that less time is spent on input of information and more time on attending to patients.
A third factor entails the resources within the organization (CPSI, N.d.). Resources include financial, human and medical equipment required to facilitate treatment. Technology is an important resource since its application is widespread in within a healthcare organization.
Human resource involves the staff that deals with the patients, with the inclusion of the management. Effective management ensures that different strategies are put in place to enhance safety of patients and are accountable for the performance of other medical staff. The management designs care processes that will maximize patient safety by focusing on the sentinel events and provide funding for other requirements that need to be incorporated. Other medical staff are required to prioritize patient safety by providing effective medical care. Their skill and competency is an essential requirement in enhancing patient safety and minimizing the occurrence of sentinel events. Since they interact directly with patients, it is their duty to implement strategies put in place to promote patient safety.
Workplace culture determines the interaction between medical providers, patients and the patients’ families. This determines the forms of communication applied to promote patient safety, such as use of alarm systems when possible danger to the patient is presented, and confidentiality between doctors and patients. The latter is important especially for patients with high risk of committing suicide, since doctors can use their professional and ethical skills to ensure that such an event does not occur.
People involved refers to the community surrounding the healthcare organization. The community provides experienced staff and other resources that are essential for patient safety management (CPIS, N.d.). The community also provides funding to the organization as a way of enhancing its effectiveness in medical care provision. The people are also tasked with the duty of responding to any sentinel events within their reach, such as preventing a patient from committing suicide, or informing the medical staff of a patient with the intent of committing suicide and preventing patient fall.
A combination of all these factors ensures that patient safety is maximized, and as a result, the performance of the healthcare organization is increased.
Processes and Techniques
From the discussion, it is evident that healthcare organizations ought to put a number of techniques and processes that can be used to investigate, prevent and control the sentinel events stated above. This arises from the fact that the occurrence of these sentinel events is usually a sign for the necessity of investigation and response (Chen et al., 2012). The measures put in place should be both effective now and in future, so as to minimize the deaths of patients or collateral damages in form of law suits. The techniques and processes that can be put in place for investigation of the sentinel events include reviewing the prevalence of the events and how they have been managed in the past, evaluate management systems and establishing inadequacies in different managerial areas, evaluating the risks and hazards presented and analyzing the qualification of the staff in promoting patient safety. These techniques are efficient in predicting the possibility of occurrence of the sentinel events discussed, and setting aside measures that can be used to promote patient safety. Evaluating management systems and identifying any inadequacies in the different areas of management is effective establishing effective communication systems and ensuring that medication is stored effectively and administered at the right time, especially to patients with psychiatric conditions. This is useful in formulating new policies for the purpose of enhancing patient safety. Evaluating risks and hazards presented also ensures that the organization identifies the probability of occurrence of the sentinel event. For example, delaying the provision of medication to a cancer patient may result in eventual death. Based on this evaluation, several methods can be put in place to ensure that such patients get their medication on time. The possibility of overcrowding when the organization has a shortage in staff ensures that there is efficient allocation of human resources for the purpose of reducing delays in treatment. Lastly, analyzing the qualification of the staff is can be said to be the most effective method of investigation. This is done by looking at how well the staff has been able to manage and minimize the occurrence of patient deaths by suicide and delay in treatments. Training can thus be considered to enhance their skills in dealing with patients. This can be applied to doctors in general hospitals who have to deal with psychiatric patients from time to time.
Moreover, prevention and control include the management of communication within and outside the organization, updating information systems so as to have up-to-date information on patients for easy identification, and improving the safety of medications. The processes stated above can only be carried out after identifying events that could cause harm, analysis of response to previous and future events and change of any response strategies that have been applied in the past (Johnson, 2016).
Studies show that communication problems account for most medical errors and also result in the occurrence of the sentinel events stated above. Increasing the effectiveness of communication procedures will entail improving the giving of orders through telephones, and verbal orders. Furthermore, critical test results that have to be verified or read back should be handed in to the required medical provider on time. Patients who have to go back in for medical tests and checkups should be well-informed to prevent cases of delayed treatments. Effective communication will prevent cases of delayed treatments, and also safeguard against other sentinel events. Subordinates should also be trained to
Updating information systems will increase the accuracy of all patient details, including high-risk patients that may be in need of extra medical attention as a way of reducing probability of occurrence of patient suicide. The use of information systems to enhance active communication will also reduce chances of delayed treatments as medical records can easily be retrieved and forwarded to physicians during checkups or before surgical procedures and other treatment.
Improving the safety of medication will reduce its access by suicidal patients. Medication with concentrated electrolytes such as potassium phosphate and potassium chloride should not be kept in patient units, especially in psychiatric wards and hospitals where most patients are known to commit suicide while still under care. This will also reduce the probability of overdosing on medication and resulting in death.
Performance assessment and Risk Management
Finally, several measures can be used to assess the overall performance of healthcare organizations and the risk management plan put in place. These measures include patient satisfaction, quality of service provided and the efficiency of resource management (Cowing, Davino-Ramaya and Szemerekosvsky, 2009). The measures stated above are used to evaluate the outcomes of the patients, medical providers and the organization, in order to establish the overall performance. Patient satisfaction only arises when the sentinel events are minimized since patient safety is maximized and number of deaths and serious injuries is reduced. The treatment processes should also be centered on the patient and their needs to ensure that the treatment is effective (Tarzimoghadam and Zakerian, 2015). The resulting effect is quality outcome, making a particular healthcare organization appealing to most patients. Effective communication and time management ensure that patients’ needs are met on time, thus the issue of delay in treatment is averted, alongside other sentinel events such as patient deaths, medication error, and operative and post-operative complications. Promoting communication between patients allows them to address different concerns and also minimize suicide.
The quality of services provided is dependent on the level of skill and professionalism of the staff (Cowing et al., 2009). High level of skill ensures that patients receive efficient and effective care, and that their safety is maximized. Critical medical procedures such as surgeries require high proficiency to minimize sentinel events. The psychiatric unit also needs to be handled by qualified psychiatrists who can help minimize patient suicide and delay in treatment of psychiatric patients. This also ensures that risk of occurrence of the sentinel events is minimized, through efficient and constant training of all staff on how to promote and ensure patient safety. Providing good quality service ensures that various medical errors are avoided, thereby enhancing patient safety.
Lastly, the efficient management of resources ensures that comprehensive and effective health care is delivered. Effective technological systems are used to measure the effectiveness of these organizations since technology determines the efficiency of all the resources put in place. This allows the staff to be effective and efficient in the provision of medical services, thus improving the overall performance of the organization and reducing exposure to risk provided by sentinel events.
It is evident that every healthcare organization is exposed to the risk of occurrence of sentinel events. However, the application of various measures ensures that the exposure of the organization to these risks is minimized, thus enhancing patient safety.
References
Canadian Patient Safety Institute. (N.d.). System Factors. Retrieved from http://www.patientsafetyinstitute.ca/en/toolsResources/PatientSafetyIncidentManagementToolkit/SystemFactors/Pages/default.aspx
Cowing, M., Davino-Ramaya, C. M. and Szemerekosvsky, J. (2009). Health Care Delivery Performance: Service, Outcomes, and Resource Stewardship
Foley. S. R. and Kelly, B. D. (2007) When a Patient dies by Suicide: Incidence, Implications and Coping Strategies. Advances in Psychiatric Treatment, 13(2), pp. 134-138.
Kim H. S., Kim Y. H., Woo J. S., Hyun S. J. (2015) An Analysis of Organizational Performance Based on Hospital Specialization Level and Strategy Type. PLoS ONE 10(7): e0132257. https://doi.org/10.1371/journal.pone.0132257
Knoll, J. L. (2012). Inpatient Suicide: Identifying Vulnerability in the Hospital Setting. Psychiatric Times, 30(6).
Tarzimoghadam, S. and Zakerian, S. A. (2015) Ergonomics in Healthcare System- Human Factor Models: A Review Article. Journal of Health and Safety at Work, vol. 5(4), pp. 87-98.
Watson, D. (2009). Sentinel Events. AORN Journal, vol. 90(6), pp. 926-929.
