*PR: Sentinel Event Statistics for First Half of 2016 (PDF)[REF: LDR, SC] Perspectives, August 2016, Vol 36, #8, Pg 4 JCp1608_B1
The five most recently reported sentinel events (relevant to psychiatric hospitals) for the first half of this year included:
#2/5: Falls
• Key causal factors: Inadequate assessment, communication failures and failure to follow established protocols and safety practices
• See also: Sentinel Event Alert Issue 55: Preventing Falls and Fall-Related Injuries in Health Care Facilities
#4/5: Patient Suicide
• Key causal factor: Inadequate psychiatric assessment
• See also: Sentinel Event Alert Issue 56: Detecting and Treating Suicide Ideation in All Settings
#5/5: Delay in Treatment (see Comments for KeyDef)
• Key causal factors: Inadequate assessment, poor planning/scheduling systems, understaffing, misdiagnosis, communication failures and human factors (e.g., memory lapses, bias)
• See also: Quick Safety Issue 9: Preventing Delays in Treatment
Tip: Note the common theme of inadequate assessment in these three risk areas and with that in mind, proactively review the adequacy and effectiveness of your assessment processes for these issues.
|
One response to “RTN1608_B1_Sentinel Event Statistics 2016a”
It should be noted/re-emphasized that the issue of TREATMENT DELAY is quite relevant to psychiatric hospitals. The definition of treatment delay includes any ordered treatment such as medications, tests, therapies, but can also include initial appointments/follow-up appointments and even consultations.