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Factors contributing to sentinel events

Part of the trust between Louisiana patients and their doctors stems from the belief that in the operating room, the surgeon will perform the right surgery on the right part of the body. Unfortunately, this is not always the case. Wrong-site, wrong-procedure and wrong-patient errors, also known as WSPEs, are the horrifying results of a serious medical error.

The Joint Commission includes WSPEs in the category of sentinel events (also known as “never events”), which refer to medical errors that result in permanent or temporary but significant harm to the patient demanding life-saving intervention or, in the worst-case scenario, patient death. Medical facilities are encouraged to report the occurrence of sentinel events to the Joint Commission to enable investigation and promote patient safety; however, such reporting is not required.

According to the Patient Safety Network, several factors may contribute to the occurrence of a sentinel event, such as a wrong-site surgery. For instance, surgeons may face pressure to value surgical output over the safety of their patients. Furthermore, although surgical timeouts are required before any invasive procedure to allow all involved medical personnel to go over the important points, these timeouts may be hurried and insufficient.

Last but not least, the medical error may occur outside of the operating room. The existing estimates with respect to the occurrence of WSPEs incorporate only the mistakes that happen in the OR, but a study using data from Veterans Affairs indicated that up to one half of WSPEs may take place outside of the OR. Communication, teamwork and an emphasis on patient safety play essential roles in reducing the likelihood of sentinel events.

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