All Content

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.

Hard-and-fast statistics on sentinel events are difficult to come by, however. Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Researchers cite a number of reasons that many incidents go unreported; among them are lack of time, fear of punishment, and confusion about the severity of events that require notification. For example, do near misses count? (See “Near Misses,” The Hospitalist, May, p. 34.) Others see no benefit to themselves or their institutions from reporting.

Studies have attempted to define the true incidence of sentinel events, but a lack of consistent language and definitions makes it difficult to put the whole puzzle together, even when sentinel events do come to the surface.

Because they are involved in the day-to-day care of patients, hospitalists are firsthand observers when many errors occur, and they have the experience and clinical judgment to give meaningful input to new incident-reporting protocols and to promote new policies through interdisciplinary teams that investigate and analyze adverse events.

Focus on Medication Errors

That said, we know that the incidence of sentinel events is much higher than it should be. As regularly reported by The Hospitalist, the problem most in the spotlight today—among researchers and the popular press—is medication errors. The IOM report says that, on average, a hospitalized patient is subject to at least one medication error per day, though error rates vary widely among hospitals. Fortunately, most errors cause no serious harm, but the costs for those that do are substantial. One study found that each preventable adverse drug event (ADE) costs a hospital approximately $8,750.

At least a quarter of medication-related injuries are preventable, according to the report. The irony is that many error-prevention methods are available today: “do not use” abbreviation lists; medication reconciliation (used to compare a patient’s medication orders with all other medications the patient is taking in order to avoid omissions, duplications, dosing errors, or drug interactions); and computerized physician order entry systems, to name a few.

With so much emphasis on patient safety and the increasing availability of sophisticated reporting and record-keeping technology, why haven’t incidence rates for ADEs and other sentinel events dropped dramatically? The answer is not that hospital personnel are lazy, incompetent, or indifferent to the safety of their patients. Experts agree that today’s doctors, nurses, pharmacists, and other medical staff are highly trained, dedicated professionals who want to practice the best medicine possible. The present system focuses on individual fault and does not foster disclosure that could lead to corrective procedures.

In fact, legal experts worry that JCAHO’s Sentinel Events Policy, which mandates self-reporting by hospitals accredited by the JCAHO, creates new problems. They suggest that self-reporting will have limited success in the absence of immunity from legal liability. One proposed solution calls for submitting self-regulatory reports to a neutral, nonsanctioning third-party entity. This approach has worked well for the airline industry.

New Patient-Care Focus

Abandoning a policy that concentrates on blame is at the heart of the improvements in patient safety proposed in the IOM report. Rather than pinpointing individual error, the new paradigm focuses on developing new systems of care that foster patient safety and help prevent sentinel events. In the absence of a finger-pointing environment, hospital personnel can freely examine what happened, discover the causes, and structure new procedures to prevent future occurrences – without fear of any retribution.

That’s the way they handle it at California Pacific Medical Center in San Francisco. In one case, when a nurse removed a dialysis catheter, the patient developed an air embolism and subsequently suffered a severe, permanently disabling stroke.

“When we investigated, we found that there was a written procedure in place to document a dialysis nurse’s credential,” says hospitalist Thomas E. Baudendistel, MD, FCAP, who is associate medical director of the hospital’s Internal Medicine Residency Program. “A, we weren’t aware of the credentialing procedure, and B, when we looked at it we weren’t sure it represented best practice. So we researched the literature and rewrote the policy. Now we schedule regular nursing education on pulling a dialysis catheter.”

In addition, the hospital set in place a follow-up plan to re-evaluate the procedure periodically. They also offer refresher training in catheter removal.

“We’ve used a similar approach in other situations,” says Dr. Baudendistel. “For example, our procedure with falls has changed. Now we use an event-based algorithm to determine whether a head CT scan is necessary.”

Hospitalists Can Lead

Hospital-based physicians are in an advantageous position to promote—as well as participate in—new initiatives for patient safety. Because they are involved in the day-to-day care of patients, hospitalists are firsthand observers when many errors occur. They have the experience and clinical judgment to give meaningful input to new incident-reporting protocols and to promote new policies through interdisciplinary teams that investigate and analyze adverse events.

Inevitably, electronic systems will replace paper-and-pen reporting and recordkeeping. Here hospitalists can take the lead, too. Unlike physicians who admit patients to multiple hospitals (each with a different information system), hospitalists practice in a single institution with only one system to learn. Hospitalists’ patient load may also help them to master new technology more quickly.

Surveys show that, while many hospitals have electronic ordering systems in place, relatively few physicians actually use them. In many cases, nurses or pharmacists place the electronic orders. Hospitalists who place their own orders can contribute to a reduction in medication errors by eliminating the pass-through of information that often causes misunderstandings.

Patient-Centric Healthcare: the New Paradigm

The traditional hospital system—and the healthcare system as a whole—are provider-oriented and provider-directed. Many patients, especially older ones, have a “doctor knows all” mindset, and they typically ask few questions—even when they don’t understand their treatment plans or exactly how they’re to take their medications when they go home. Case in point: A patient who was discharged from the hospital died at home shortly thereafter. The cause: His wife misunderstood the instructions for his pain medication and mistakenly applied six transdermal patches to his skin at one time instead of the single patch she should have applied. The multiple patches delivered a fatal overdose of the narcotic fentanyl.

Many experts believe that better informed—and empowered—patients are the key to reducing the number of sentinel events, including ADEs. The IOM report advocates a shift from a provider-centered to a patient-centered healthcare model. In this new paradigm, hospitalists would be much more expansive in their communications with patients. With regard to medications in particular, the report recommends that a physician:

  • Review the patient’s medication list routinely and during care transitions.
  • Review different treatment options.
  • Review the names and purposes of all medications.
  • Discuss when and how to take the medication.
  • Discuss important and likely side effects and what to do about them.
  • Discuss drug-drug, drug-food, and drug-disease interactions.
  • Review the patient’s (or surrogate’s) role in appropriate medication use.
  • Review the role of medications in the overall context of the patient’s health.

There are barriers to surmount before patients can become full partners in their healthcare. One of the most obvious is that patients need to be much better informed, and—when they are incapable of making appropriate decisions—they need surrogates to stand in for them. Patients need access to trustworthy and understandable information both online and in printed materials.

The IOM report recommends a government-sponsored national drug-information hotline; medication leaflets that provide standardized language in a manner that is appropriate for various age, literacy, and visual acuity levels; and development of personal health records.

PeaceHealth in Washington state took up the challenge of developing personal health records in 2001. PeaceHealth’s Project Manager, Mary Minniti, invited patients to design the system for self-management and communication among care team members. Today, the Shared Care Plan Personal Health Record is a reality, and Marc Pierson, MD, who is PeaceHealth’s regional vice president of Clinical Information and Special Projects, says “early evidence suggests that this type of tool promotes personal responsibility and positively affects patients’ confidence and active participation in their care.”

The tool is available on CD from for those who would like to adopt it for their use.

Final Thought

The bad news is that sentinel events still take a staggering human and economic toll. The good news is that momentum is building for an important change in the way healthcare is delivered. Better communication, new technologies, and, perhaps most importantly, true provider-patient partnerships hold the promise of making hospital healthcare much safer. Hospitalists play a key role in this new scenario. TH

Joen Kinnan is a freelance medical writer based in Chicago.

The Hospitalist-PCP Handoff: A Weak Link in the Chain?

Hospitalists provide continuity of care within the inpatient setting, but what happens when the patient returns to the care of his or her primary care provider (PCP)? Although every handoff has the potential for someone to drop the ball and lose information, the discharge handoff is often the most critical. This is partly because patients are often left on their own to make follow-up appointments with their PCPs and take their medications as ordered. Elderly patients and those with language barriers may not get it right, creating the potential for serious problems. This risk makes good hospitalist-PCP handoff communications imperative.

In their book Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, Robert Wachter, MD, and Kaveh Shojania, MD, cite early discharge—“sicker and quicker”—as another source for potential problems at handoff. They report that nearly one in five patients suffered an adverse event in the transition from hospital to home, two-thirds of which could have been prevented with better communication. A case in point: In the hospital, a patient was started on a new heart medicine known to cause major swings in blood potassium, but no one set up post-discharge plans for monitoring blood chemistry. The patient developed extreme weakness and was eventually found to have a potassium level double the normal range—enough to have been fatal. A simple follow-up phone call might have averted this situation.

Studies show that primary care physicians want this handoff communication. A survey of the members of the California Academy of Physicians found that PCPs prefer to talk by telephone with the hospitalists managing their patients—at admission and discharge. Only slightly more than half (56%) of PCP respondents believe their communication with hospitalists was adequate, though the majority liked the idea of hospitalist care.

Overwhelmingly, patients’ primary physicians stated that communication about discharge diagnoses and discharge medications was extremely important, yet only a third said that discharge information arrived in a timely manner (i.e., before the patient’s first visit to the PCP after hospital discharge).

Some experts suggest that PCPs make so-called “continuity visits” to their hospitalized patients as a means of enhancing continuity of care. If coordinated with hospitalists’ rounds, these visits could establish a basic working relationship between the hospitalist and the PCP that would mitigate errors during the handoff at discharge. Continuity works both ways, though. Hospitalists who follow up with patients after discharge help to ensure that patients understand their medication regimens and that things are going as planned.

Post-discharge follow-up is in the best interests of hospitalists, too. Legal experts point out that physicians have a legal duty to provide follow-up care to patients with whom they have a relationship. According to one report, “The obligation to provide follow-up care endures even when the patient misses a scheduled appointment or does not adhere to the follow-up regimen. In general, the physician who began the care must fulfill that obligation. An essential component of follow-up care includes educating the patient about what symptoms require follow-up care and why it is important. The duty to provide adequate follow-up care is shared by the hospitalist and the PCP.”1—JK


  1. Alpers A. Key legal principles for hospitalists. Dis Mon. 2002 Apr;48(4):197-206.

Next Article:

   Comments ()