Responding to a Sentinel Event: Why having a policy in place is critical

People ask me – what is the most difficult part of your day to day job as a Hospital CEO?  For me, responding to a sentinel event where, a patient is harmed and that harm results in death or serious physical or psychological injury is one of the most difficult responsibilities of the position.  How effectively an organization responds to a sentinel event is directly proportional to how important patient safety and quality is to that same organization.  Since studies have indicated that at least 10 per cent of the patients that attend any healthcare organization on a daily basis is harmed by us and not healed, addressing sentinel events is an unfortunate reality.

It is also an unfortunate reality that many hospitals do not have a sentinel event response policy.  One is generally required for accreditation purposes.  However, there is a big difference between having one and having one that is effective.  If your organization does not have one or you have not looked at your sentinel event policy for awhile, it is not something you want to create as you are responding to an event.  Responding to the event itself will take all of your organization’s energy and focus.  Drafting an effective policy at the same time you are responding to an event is not wise and not recommended.  That would be the equivalent of changing a flat tire going 100 km/h on a busy highway.  Also, conducting a table-top response exercise to a mock sentinel event using your policy is also a good idea rather than testing it for the first time when an event occurs.

When drafting or reviewing your sentinel event policy, I suggest you look at the policy from the position of the patient and/or family member of the patient that was harmed.  What information would you want to know, how would you want that information told to you and when would you want that information disclosed to you or your loved one?  From meeting new team members at our new-staff orientation to my day-to-day role, I always try to put myself in the position of the patient/family that is attending our organization.  I always say to our team members, “When in doubt over how to respond to situations, ask yourself this question, how would I want my loved one to be treated/informed?  You follow that answer and you will never be wrong.”

An effective sentinel event policy will contain the following key elements:

  • Is the harm isolated or does action need to be taken immediately to stop further harm to be individual patient or other patients?
  • Clinical team to be made aware immediately.
  • One of the following: CEO, Chief of Staff and Chief Nursing Executive to be notified; it is up to them to notify each other.
  • Make sure you have a point person for responding to the incident.  For my organization, it is the CEO, Chief of Staff or CNE as point person, always.  The CEO needs to be directly involved throughout the response to the event.
  • Point person works with clinical team on gathering information to notify patient and/or family immediately.  Ensure you have enough information to respond to the questions:  how, what, why, when and what next.
  • Make sure you have the right people at the disclosure meeting with the patient/family.  You need to have a contact person for the family to reach out following the first meeting.
  • Generally, the patient/family is not ready to ask any questions at the first meeting.  They are just digesting what you are telling them.  Many questions will follow the first meeting and you must be prepared for that ongoing dialogue.  Appoint someone that the family can call 24/7.
  • Ensure the necessary emotional, physical and psychological support is available for the impacted patient/family.
  • That point person ensures a sentinel event response team is assembled.  This team meets regularly with prepared agendas, reporting on actions assigned to them and discussing next steps.
  • Make sure relevant stakeholders are notified including your Board of Directors, internal staff, relevant Ministries and other healthcare providers in the region to name a few.
  • Start addressing the root cause of the sentinel event or respond to the sentinel event if it is occurring over multiple days.

Timing of notification to the patient and/or family member is always debated.  Many people who do not even want to notify the patient and/or family (yes there are always some of them) will use the excuse that you do not have all the facts with exact certainty as a reason to delay disclosure to family and/or a patient.  Do not wait for perfection of all the facts before you notify the patient/family. You have to balance timing of disclosure with waiting for all the facts.  Waiting for all the facts is most of the time not reasonable and those questioning or debating whether one needs to even notify the patient and/or family will use the lack of “all the facts” to delay notification from happening at all.

Once the event has been addressed, you need to focus on the root cause of how the event occurred, examine your response to the event, did it follow policy and/or does the policy need to be revised and the psychological impact to your team members?  Do not focus on “Who did it” but on “How did it happen”.  Do not forget that your team members are traumatized by the event as well and may need some support to address their ongoing issues.

I have always stated, as a system, we need to accept that mistakes do happen and we have to learn from them to avoid them from happening again.  The only chance we have in reducing patients being harmed is to accept responsibility, treat the patient/family as if they were your loved one and learn from the mistake to prevent others from happening.