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Halting the Growing Risks of Sentinel Events & RSIs with Updated Protocols

Feb 16, 2024

Understanding and preventing sentinel events is vital for healthcare facilities. These “never events” serve as critical indicators of system weaknesses and a need to assess current protocols. By addressing these underlying issues, healthcare facilities can enhance patient safety and overall quality of care. Proactively managing and preventing these events also helps build and maintain trust with patients and the community, preserving the facility’s reputation.

Defined by the Joint Commission as patient safety events leading to death, permanent harm, severe temporary harm, or intervention required to sustain life, sentinel events have been on the rise, with significant implications for patients, staff, and healthcare institutions. And according to research by the Joint Commission, retained surgical items (RSIs) have been the second leading sentinel event reported by healthcare professionals for the last two years.

Let’s explore the prevalence of RSIs and how to prevent this never event in your facility.

What is a Sentinel Event?

A sentinel event is a term used in healthcare to describe an unexpected occurrence or variation involving death or serious physical or psychological injury to a patient unrelated to the natural course of the patient’s illness. These events are called “sentinel” because they signal the need for immediate investigation and response. The goal is to identify and address the root causes to prevent similar events from recurring.

The concept of sentinel events is often associated with the Joint Commission, which accredits and certifies healthcare organizations in the United States. The Joint Commission defines specific criteria for events that trigger an immediate review, investigation, and analysis by the healthcare organization. Common examples of sentinel events include RSIs, wrong-site surgery, patient falls resulting in serious injury, medication errors leading to harm, and unexpected death during or after a procedure.

Healthcare organizations use the analysis of sentinel events to implement improvements in processes, communication, and systems to enhance patient safety and prevent future occurrences. Reporting and learning from these events are crucial for continuous quality improvement in healthcare settings.

Recent Findings

According to a report from Becker’s Hospital Review on the Joint Commission’s data for the first half of 2023, there is a concerning increase in sentinel events, continuing a trend from the previous year^1,2. In 2022, there were 1,441 recorded sentinel events², setting a record that 2023 seemed on track to match or surpass¹. And while the landscape of sentinel events has evolved, with treatment delays and suicides decreasing, but incidents like assaults and wrong-site surgeries growing in prevalence, RSIs remain the second most commonly reported event on the list, notably accounting for 9 percent of all reported sentinel events^1,2. Looking at this data, it becomes apparent that RSIs, including lost sharps, have been a consistent concern for healthcare institutions.

Preventing RSIs with Updated Miscount & Lost Sharp Protocols

Sentinel events lead to serious issues for patients and can have cascading effects on healthcare staff and institutions. Patients may endure prolonged pain, infections, or other complications, impacting their overall health and well-being. Healthcare staff, in turn, may grapple with emotional distress stemming from the unintended harm caused to patients. The facility may also face repercussions, including legal claims, regulatory penalties, and a tarnished public image.

Healthcare institutions must prioritize developing and implementing updated protocols to minimize these risks. For instance, protocols related to the counting and handling of sharps or needles in surgical settings need constant refinement to keep pace with evolving medical practices and technologies. Despite advancements in surgical instruments and the trend toward smaller needles, protocols for needle miscounts have not necessarily adapted accordingly. This creates a potential for errors and adverse events.

Investing in the right tools for the operating room is crucial for preventing sentinel events. Advanced tracking and detection systems can significantly contribute to better management of equipment miscounts and reduced occurrence of RSIs. Implementing state-of-the-art technology that can precisely locate surgical instruments, like needles or broken instrument fragments, throughout a procedure can enhance accuracy and reduce the likelihood of items being unintentionally left inside a patient. Such proactive measures can potentially improve patient safety, contribute to healthcare staff’s well-being, and protect healthcare organizations’ institutional integrity.

A New Approach is Necessary

Addressing the alarming rise in sentinel events, particularly RSIs, demands a comprehensive approach beyond acknowledging the issue. The Joint Commission’s findings underscore the urgency for healthcare facilities to reassess and fortify their protocols, embracing technological advancements to safeguard patient safety. As healthcare professionals confront the challenges posed by evolving medical practices, embracing innovative solutions is not just an option; it’s an imperative step towards a safer, more reliable healthcare landscape.

The Melzi Sharps Finder is an excellent example of the tools that OR staff should include in their standard RSI-prevention procedures. Capable of locating needles as small as 7-0³, this tool can help OR staff quickly and efficiently find lost sharps in vivo, potentially improving patient safety, saving time and money in the OR, and protecting reputations.

To learn more about Melzi, our mission to improve patient outcomes with cost-effective technology, and the Melzi Sharps Finder, explore our site or get in touch today.