Sentinel Events

926 • AORN JOURNAL • DECEMBER 2009, VOL 90, NO 6 he OR environment is highly complex. If factors such as time pressures and conflicting and competing priorities for OR time, staffing, and instrumentation are not appropriately communicated, they may contribute to an error with an unexpected, untoward patient outcome. In addition, every surgical patient has a unique set of conditions and comorbidities, which must be considered in the plan of care. This can challenge even the most experienced perioperative team; however, team members can promote safe patient care for any surgical patient by using clear communication, precise coordination, and proficient teamwork. During the past 10 years, health care leaders have focused on medical errors and prevention. This, in part, can be attributed to the Institute of Medicine’s report To Err is Human: Building a Safety Health System, which revealed that 44,000 to 98,000 patient deaths occur annually in the United States as a direct result of preventable medical errors. Crossing the Quality Chasm: A New Health System for the 21st Century was a follow-up publication that offered suggestions for needed health care reform. After a decade of increased awareness, identification of strategies, and health care initiatives to address many challenging issues related to medical errors, it is apparent that a facility should never assume “it will never happen here.” Medical errors continue to occur at a rate of 195,000 patients annually in the United States, ranking medical errors as the eighth leading cause of death. The Joint Commission is committed to improving patient safety and quality of care and “stopping dangerous and potentially deadly breakdowns in patient care.” Each member of the perioperative team should be aware of the Joint Commission’s patient safety strategies, which include • sentinel event policies and procedures and Sentinel Event Alerts; • patient safety standards and guidelines; and • National Patient Safety Goals. The 2009 Joint Commission National Patient Safety Goals and the implementation of the Universal Protocol for improvement of patient safety have previously been reviewed in the Patient Safety First column. This column reviews elements for compliance with the Joint Commission’s sentinel event program and information a facility should consider when a sentinel event occurs.