![]() Eliminating punitive action is critical to improving patient outcomes, they say. In a joint statement, they encourage organizations to adopt a culture of learning from adverse events, rather than a culture of blame and punishment. 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.Īnd ACOG, SMFM, and AWHONN agree. 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. 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. 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." In addition, the definition of severe maternal morbidity has changed. 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. Causing some confusion among obstetric providers is that not all cases that meet the definition of severe maternal morbidity are considered sentinel events. Any intrapartum (related to the birth process) maternal death or severe maternal morbidity.Īmong the listed examples of a sentinel event is severe maternal morbidity (see Box).Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care.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.Severe neonatal hyperbilirubinemia (bilirubin > 30 mg/dL).Unintended retention of a foreign object in a patient after an invasive procedure, including surgery.Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure.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. ![]()
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