Nursing News

JCAHO: Not All Sentinel Events Occur in the ED

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By Jennifer Larson, NurseZone feature writer

The Joint Commission on the Accreditation of Healthcare Organizations released a sentinel event alert June 17 showing that these events can and do occur in many hospital departments, not just in the emergency department.

According to the alert, emergency departments are the source for about half of the reported event cases of patient death or permanent injury due to delays in treatment. However, serious events also occur in intensive care units, medical-surgical units and other hospital departments.

JCAHO looked at 55 reported cases of delays in treatment and found that 29 cases originated from emergency departments, while 26 cases originated in hospital intensive care units, medical-surgical units, inpatient psychiatric hospitals, the operating room, freestanding and hospital-based ambulatory care services, and in the home care setting. Patient death resulted in 52 of the 55 cases of delays in treatment.

Misdiagnosis accounted for 42 percent of the delays in treatment. Delayed test results, physician unavailability, incomplete treatment, delayed administration of ordered care, a patient left unattended, paging system malfunction, delayed initial assessment and a patient’s inability to find the emergency room entrance were cited as other reported factors contributing to delay in treatment.

JCAHO reported 23 cases of misdiagnosis, with meningitis cited as the most frequently missed diagnosis.

The alert also reported that there are multiple root causes for such occurrences. Most  organizations cited a breakdown in communication, most often with or between physicians, according to JCAHO. Other factors included patient assessment process, continuum of care issues which most often related to discontinuity of care across settings or shifts, orientation and training of staff, availability of critical patient information, staffing levels and availability of physician specialists.

Staffing was the most commonly cited root cause in emergency departments, accounting for 34 percent. Overcrowding was cited as a contributing factor in 31 percent of the emergency department cases.

JCAHO issued recommendations that hospitals implement processes and procedures to improve staff-to-staff communication, including communication between resident and attending physicians. It also recommended that hospitals implement face-to-face interdisciplinary change-of-shift debriefings and find ways to reduce staff reliance on verbal orders or institute a verification process for the use of verbal orders.

Finally, the commission suggested that hospital emergency departments institute strategies to “maintain a high index of suspicion for meningitis.”

June 25, 2002. © 2002. All Rights Reserved.