"Sentinel event" from_date:2012

The influence of cognitive and affective components of the sentinel event on alcohol use following a brief intervention with trauma patients. Alcohol-related injury is a sentinel event, an unanticipated medical event that may prompt a re-evaluation of health behaviors, such as alcohol use. Few studies have examined the psychological components of the sentinel event that motivate behavior change . These results provide preliminary support for further consideration of an affective component of alcohol-related injuries that may motivate subsequent reductions in drinking following a sentinel event.

The relationships between patient safety culture and sentinel events among hospitals in Saudi Arabia: a national descriptive study. Sentinel events (SEs) can result in severe and unwanted outcomes. To minimize the fear of sentinel events reporting and the occurrence of sentinel events, patient safety culture improvements within healthcare organizations is needed. To our knowledge, limited studies explored the relationships between patient safety culture and sentinel events on a local level and no research has been conducted at the national level in Saudi Arabia. This study aimed to explore the relationships between the patient safety culture and the reported-SEs on a national level during the year 2020 in Saudi hospitals. This was a descriptive study. We utilized two data sources

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study. Root cause analysis (RCA) is a systematic approach, typically involving several stages, used in healthcare to identify the underlying causes of a medical error or sentinel event. This study focuses on how members of a Norwegian RCA team experience aspects of an RCA process and whether it complies with the Norwegian RCA method. Based on a sentinel event in which a child died unexpectedly during childbirth in a Norwegian hospital in 2021, the following research questions are addressed: 1. What was the RCA team's experience of the RCA process? 2. Was there compliance with the Norwegian RCA method in this case? A case study was chosen out of the desire to understand complex social phenomena

Establishing a Guide for Developing Organizational Support in Healthcare Following a Critical or Sentinel Event. Health professionals require support and recognition to help manage the well-known impact of critical or sentinel events relating to patient care. The potential distress can be magnified or mitigated by the response of the organization and colleagues. However, strategies

Category II Intrapartum Fetal Heart Rate Patterns Unassociated With Recognized Sentinel Events: Castles in the Air. The evolution of continuous electronic fetal heart rate (FHR) monitoring has presented the obstetrician with a critical clinical conundrum: basic science observations suggest that such monitoring might be associated with improved long-term neurologic outcomes, yet, after a half

Scandal as a Sentinel Event - Recognizing Hidden Cost-Quality Trade-offs.

Older Adult Falls in Emergency Medicine-A Sentinel Event. Standing-level falls represent the most frequent cause of trauma-related death in older adults and a common emergency department presentation. However, these patients rarely receive guideline-directed screening and interventions during or following an episode of care. Reducing injurious falls in an aging society begins with prehospital

Aggregate analysis of sentinel events as a strategic tool in safety management can contribute to the improvement of healthcare safety. To examine if clustering of root causes of sentinel events (SEs) can contribute to organisational improvement of healthcare and patient safety by providing insight into organisational risk factors, patterns and trends. Retrospective, cross-sectional review of SEs

Idiopathic Sudden Sensorineural Hearing Loss Is Not a Sentinel Event for Acute Myocardial Infarction. Given ongoing debate about the suggested association, the primary objective was to determine if idiopathic sudden sensorineural hearing loss (ISSNHL) was a sentinel event for acute myocardial infarction (AMI) in adults. Case-control study. United States MarketScan administrative health claims

Gastrointestinal Bleed from Erosive Gastritis and Duodenitis: A Sentinel Event of Invasive Lobular Carcinoma of the Breast and a Diagnostic Dilemma Metastasis from breast cancer to the gastrointestinal (GI) tract is uncommon, and such events presenting as GI bleeding are exceedingly rare. In some individuals, the absence of classical findings of primary breast cancer coupled with the non-specific

Involving Patients and Families in the Analysis of Suicides, Suicide Attempts, and Other Sentinel Events in Mental Healthcare: A Qualitative Study in The Netherlands Involving patients and families in mental healthcare is becoming more commonplace, but little is known about how they are involved in the aftermath of serious adverse events related to quality of care (sentinel events, including suicides). This study explores the role patients and families have in formal processes after sentinel events in Dutch mental healthcare. We analyzed the existing policies of 15 healthcare organizations and spoke with 35 stakeholders including patients, families, their counselors, the national regulator, and professionals. Respondents argue that involving patients and families is valuable to help deal

Risk factors for metastatic prostate cancer: A sentinel event case series. Root cause analysis is a technique used to assess systems factors related to "sentinel events"-serious adverse events within healthcare systems. This technique is commonly used to identify factors, which allowed these adverse events to occur, to target areas for improvement and to improve health care delivery systems. We

Hip Fracture in the Elderly Patients: A Sentinel Event. Hip fracture in the elderly patients is associated with increased morbidity and mortality. There is great need for advance care planning should a patient fail to rehabilitate or experience an adverse event during or after recovery. This study was performed to evaluate for palliative care consultation and changes in code status

Sentinel Events Preceding Youth Firearm Violence: An Investigation of Administrative Data in Delaware. Accurately identifying youth at highest risk of firearm violence involvement could permit delivery of focused, comprehensive prevention services. This study explored whether readily available city and state administrative data covering life events before youth firearm violence could elucidate violence perpetration, though multiple other sentinel events were informative. The mean number of sentinel events experienced by youth committing firearm violence was 13.0 versus 1.9 among controls (p<0.0001). Within the sample, 84.1% of youth experiencing a sentinel event in all five studied domains ultimately committed firearm violence. Youth who commit firearm violence have preceding patterns of life

Acute Perinatal Sentinel Events, Neonatal Brain Injury Pattern, and Outcome of Infants Undergoing a Trial of Hypothermia for Neonatal Hypoxic-Ischemic Encephalopathy. Infants with perinatal sentinel events in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network Hypothermia for Encephalopathy Trial had more basal ganglia and thalamus lesions on brain magnetic resonance imaging but similar neurodevelopmental outcomes at 18 months of age than infants without perinatal sentinel events. Outcomes correlated with the neonatal magnetic resonance imaging findings.

Microbiological sentinel events at neurological hospital: a retrospective cohort study. The purpose of this study is to describe the epidemiological surveillance of microbiological sentinel events (SEs) carried out between 2012 and 2014 at the Neurological Hospital Carlo Besta, Milano, Italy. The setting is inpatient care with multidrug-resistant infections. The aim of the procedure

One Health and Cyanobacteria in Freshwater Systems: Animal Illnesses and Deaths Are Sentinel Events for Human Health Risks Harmful cyanobacterial blooms have adversely impacted human and animal health for thousands of years. Recently, the health impacts of harmful cyanobacteria blooms are becoming more frequently detected and reported. However, reports of human and animal illnesses or deaths cyanobacteria-associated animal illnesses and deaths have served as sentinel events to warn of potential human health risks. We find that illnesses or deaths among livestock, dogs and fish are all potentially useful as sentinel events for the presence of harmful cyanobacteria that may impact human health. We also describe ways to enhance the value of reports of cyanobacteria-associated illnesses and deaths

Sentinel Events in Lumbar Spine Surgery. Retrospective national database analysis. A national population-based database was queried to investigate the incidence and perioperative outcomes associated with sentinel events in lumbar spine surgery. Sentinel events in lumbar spine surgery can have significant medical, social, economic, and legal implications. The incidence and perioperative outcomes associated with these events have not been well characterized. Data from the Nationwide Inpatient Sample was queried from 2002 to 2011. Patients who underwent lumbar spinal surgery were identified. Sentinel events including bowel or peritoneal injury, vascular injury, nerve injury, retention of foreign objects, and wrong-site surgery were identified. Patient demographics, comorbidities (Charlson

Sentinel Events in Cervical Spine Surgery. Retrospective cohort. A national population-based database was queried to investigate the incidence of sentinel events in cervical spine surgery as well as the associated perioperative outcomes. Sentinel events in cervical spine surgery are potentially catastrophic complications. The incidence and perioperative outcomes associated with sentinel events in cervical spine surgery have not been well characterized. The Nationwide Inpatient Sample was queried from 2002 to 2011. Patients who underwent elective cervical spinal surgery were identified. Sentinel events including esophageal perforation, vascular injury, nerve injury, retention of foreign objects, and wrong-site surgery were identified. Patient demographics, comorbidities (Charlson Comorbidity Index

The Medical Emergency Team Call: A Sentinel Event That Triggers Goals of Care Discussion. Several studies have questioned the effectiveness of rapid-response systems when measured by outcomes such as decreased overall hospital mortality or cardiac arrest rates. We studied an alternative outcome of rapid-response system implementation, namely, its effect on goals of care and designation of do the medical emergency team call. The medical emergency team implementation significantly changed the trend of do-not-resuscitate orders (p < 0.001) but had no impact on hospital mortality rate (p = 0.638). Implementation of a rapid-response system was associated with an increase in do-not-resuscitate order placement. As a sentinel event, medical emergency team activation and transfer to a critical care unit