Sentinal Events

Nigel is doing a lot of reading and studying lately on the NHS (UK's National Health Service) in preparation for interviews. We were talking about one hospital he had visited which had the stairs almost inaccessible to the public leaving the elevator the only obvious option. The hospital didn't want patients suicidally throwing themselves off a high floor down the stair well to the bottom. He described this as one example of a sentinel event that a hospital wants to avoid at all costs. There were a list of these sentinel events that he listed to my horror that would be catastrophic for any hospital to have happen. One that he had mentioned to me that doesn't seem to be on this list is child kidnapping from a hospital. The following is from the link he sent me: What is a Sentinel Event? A Sentinel Event is a subset of adverse events specified by the Department of Human Services (DHS). These events rarely occur but are more serious and are therefore reported to DHS and investigated immediately using a Root Cause Analysis process. DHS describes a Sentinel Event as a relatively infrequent, clear-cut event that occurs independently of a patient's condition. They commonly reflect hospital systems and process deficiencies and result in unnecessary outcomes for patients. DHS has specifically outlined 9 Sentinel Events, which must be reported: 1. Procedures involving the wrong patient or body part 2. Intravascular gas embolism resulting in serious neurological damage or mortality 3. Haemolytic blood transfusion resulting from ABO incompatibility 4. Patient suicide in hospital 5. Retained instrument or other material after surgery, requiring re-operation or further surgical procedure 6. Medical error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs 7. Maternal death or serious disability associated with labour or delivery 8. Infant discharged to wrong family 9. Other