Sentinel Events and Severe Maternal Morbidity

February 12, 2015

The Joint Commission has revised its definition of sentinel event, causing confusion about how these events now relate to severe maternal morbidity.

In January 2015, the Joint Commission announced a revised definition of a sentinel event for all specialties, and The Council on Patient Safety in Women's Health dedicated one of their Safety Action Series to address this change and how it relates to severe maternal morbidity. 

Can You Identify a Sentinel Event?

- This quiz will test your understanding of what constitues an obstetric-related sentinel event. 

The revised definition of sentinel event is any patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm.1

The Joint Commission considers "severe temporary harm" to be any "critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition."

Box. Examples of Events Considered "Sentinel" by the Joint Commission

•Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 h of discharge, including from the hospital’s emergency department (ED).

•Unanticipated death of a full-term infant.

•Discharge of an infant to the wrong family.

•Abduction of any patient receiving care, treatment, and services.

•Any elopement (ie, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the ED) leading to death, permanent harm, or severe temporary harm to the patient.

•Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups).

•Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the hospital or any staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital.

•Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure.

•Unintended retention of a foreign object in a patient after an invasive procedure, including surgery.

•Severe neonatal hyperbilirubinemia (bilirubin > 30 mg/dL)

•Prolonged fluoroscopy with cumulative dose > 1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or > 25% above the planned radiotherapy dose.

•Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care.

•Any intrapartum (related to the birth process) maternal death or severe maternal morbidity.

Among the listed examples of a sentinel event is severe maternal morbidity (see Box). Causing some confusion among obstetric providers is that not all cases that meet the definition of severe maternal morbidity are considered sentinel events. For obstetrics, the Joint Commission considers severe maternal morbidity a sentinel event only if the outcome was unexpected in relation to the condition being treated. In addition, the definition of severe maternal morbidity has changed. The new definition (below), from the American College of Obstetrics and Gynecology, the US Centers for Disease Control and Prevention, and the Society of Maternal and Fetal Medicine, replaces "blood products" with "RBCs."

Severe Maternal Morbidity: A patient safety event that occurs intrapartum through the immediate postpartum period (24 hours) that requires the transfusion of 4 or more units of RBCs (previously defined as blood products, such as fresh frozen plasma, packed red blood cells, whole blood, platelets) and/or admission to the ICU.

There is some concern that defining giving blood or sending a patient to the ICU, which generally are actions of good patient care, as a sentinel event will cause physicians to worry about "getting reviewed" and possibly have a negative impact on patient care. However, Ron Wyatt, MD, MHA, DMS (HON), Medical Director, Healthcare Improvement, the Joint Commission, emphasizes that the reporting process of any sentinel event is not meant to be punitive or to have any outcome other than risk identification and future risk reduction/prevention.

And ACOG, SMFM, and AWHONN agree. In a joint statement, they encourage organizations to adopt a culture of learning from adverse events, rather than a culture of blame and punishment. Eliminating punitive action is critical to improving patient outcomes, they say. In addition, they suggest that "all cases of severe maternal morbidity, whether sentinel events or not, undergo a thorough and credible multidisciplinary comprehensive review and analysis, resulting in an action plan for improvement, when appropriate."2 (Sample severe maternal morbidity review forms are available for request here.) 

Again, only unexpected events or outcomes will be considered sentinel and reviewable. For example, if transfusion of 4 units of RBCs is needed because of placental previa, it would not be considered a sentinel event because transfusion is an expected outcome of the condition.

To help obstetric providers better understand these changes, the Council on Patient Safety in Women’s Health Care, supplied case examples of what would and would not constitute a sentinel event. Take this quiz to test your understanding of what constitutes a sentinel event.

References:

1. The Joint Commission. Comprehensive Accreditation Manual for Hospitals, Update 2, January 2015: Sentinel Events: SE-1. Available at: http://www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf.

2. Kilpatrick SJ, Berg C, Bernstein P, et al. Standardized severe maternal morbidity review: rationale and process. Obstet Gynecol. 2014;124:361-366.