Sentinel Events

In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.

An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.

In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. Unfortunately, it was one bag too many; the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal.

An X-ray shows a 13” long, 2” wide surgical retractor that was accidentally left in the body of Donald Church, 49, of Lynnwood, Wash., by a University of Washington Medical Center (UWMC) surgeon during an operation to remove a tumor on June 6, 2000. The stainless steel retractor, resembling a metal ruler, slipped from the hands of a distracted doctor during the procedure. When Church complained of unusual post-operative pain, other doctors discovered the retractor during a CAT scan and surgically removed the device soon after. UWMC paid Church $97,000 after accepting responsibility for the mistake.

The Human Toll

Such sentinel events are all too common. According to a just-released report, Preventing Medication Errors, prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. and kill thousands. The annual cost: at least $3.5 billion. But medication mistakes are just part of the picture.

Sentinel events—unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence—can happen anywhere along the healthcare continuum, in any setting. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function.

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