Patient Safety & Clinical Quality

Sentinel Events & Patient Safety: The Disturbing Data, Part 2

This blog identifies and examines a major barrier hindering improvements in the healthcare industry, based on TJC Root Cause Analysis.

sentinel events and patient safety part two blog header

In Part 1 of this blog post, we looked at the Summary of Sentinel Events that was released by The Joint Commission (TJC) on February 9, 2016 (1) and compared the number of affected patients in our hospitals (936 reports) to the recent recall of Takata airbags by Takata airbag recall and patient safetythe National Transportation and Safety Board (NTSB), which have claimed the lives of 10 U.S. drivers.

This relationship resulted in the question, “Where are the consumer watchdogs for healthcare?" (Axlund, 2016)

The NTSB has recalled more airbags since I wrote Part 1, even without the occurrence of additional driver injury or death.

The continuation of this blog identifies and examines a major barrier hindering improvements in the healthcare industry, based on TJC Root Cause Analysis, and outlines observations that must be made when considering solutions to make advances in patient safety at your facility.

If you haven’t had an opportunity to read Part 1 of the blog, or would just like to review the discussion, here is the link.

I would like to raise the red flag here and disclose that if you (or your facility) are not sentinel events and patient safetyamenable to taking a cold, hard critical look at your hospital, observing for and changing processes that just aren’t safe and are only looking for quick, duct tape solutions - this article is probably not for you.

As quoted by Frederick Douglass, “Without a struggle, there can be no progress” (2); and the observations suggested below need to be highly critical and objective and any solutions will be complex to implement, require vigilant management and monitoring, and will likely need to be worked and reworked in order to be successful.

Reflecting back on TJC’s Root Cause Analysis (RCA), which identified Human Factors, Leadership, and Communication as the most frequent root causes of sentinel events in 2015 (The Joint Commission, 2016), we will discuss critical observations required to get started on the path to high reliability and reducing patient harm, because in essence, these three root causes all relate to one MAJOR thing that most of the hospitals in the United States are missing the mark on:

A Strong Culture of Safety - this is the KEY component!

The most important facet of improving patient safety is commitment to the cause. Does your facility have a live and active commitment to keeping patients safe from harm? The commitment that everyone adheres to and that is openly discussed throughout the hospital daily and not just when an event occurs or The Joint Commission is due to show up on the doorstep any day? In other words, do they “walk the walk” or just “talk the talk”?

I have been in many hospitals during my career and I have yet to walk into one and interact with and observe staff (leadership, front-line, non-clinical) who not only feel that safety is the #1 focus of their facility, their behaviors actually match what’s coming out of their mouths. They may be able to regurgitate what they’ve been told, but saying and doing are two completely different things and it is very easy to tell where the safety culture of a facility is by just observing the environment, how staff interact with each other, and how patients are cared for.


Make the following observations to evaluate where your facility is at:


Are "near-misses" and Sentinel Events transparently shared throughout the facility,2 fighter jets crossing paths in the sky or are they swept under the rug as they have been for so many years in the past? Last week, I was in a facility where an employee openly admitted that he oftentimes “turned the other cheek” when a safety issue was discovered – really?


Are you skimping on safety?

Is patient (and employee) safety something that’s presented during orientation and maybe once a year during annual competencies? painter standing on a stack of bucketsThere is NO excuse for not having regular mandatory safety meetings and I’m not talking about the high-level executive or leadership meetings – these discussions have to be had throughout all levels of the organization on a regular basis. Involve past patients, who bring to the table a different perspective that not many staff members get to experience.


Is your staff empowered?

Is the culture in your facility such that any staff member, no matter if it is a healthcare, environmental, or ancillary professional, feels welcome to intervene (without retribution) when a potential risk to a patient is observed? How many potential events could be avoided by someone just speaking up?


How well and how often do leaders communicate with the front-line staff?

Do leaders know the names of the people that work for them and where it is they worknurses in scrubs standing in a hospital hallway within the facility? The ability to communicate is something we all do, one way or another, but in order to do it effectively, leadership must set the tone and open the channels; in other words, effective communication HAS TO COME FROM THE TOP.


In Part III, we will look at processes that, with implementation and monitoring may help to kick start your hospital’s transition into a high-performance and high-reliability organization.

It’s time to stop ignoring safety in our facilities. Too many patients have been injured or killed in U.S. hospitals and there are no longer any excuses for this happening….start taking the steps to turn your organization around, before it’s too late for one of your patients.


Have you checked out our recent ebook Checklists Vs. Hospital Tracers? Download for free to learn which may be best for your hospital.

Checklist vs Tracers eBook cover image

Works Cited

(1) Axlund, W. (2016, 3 10). Readiness Rounds Blog. Retrieved from

(2) Douglass, F. (n.d.). Brainy Quote. Retrieved from Brainy Quote:

(3) The Joint Commission. (2016, 2 9). Sentinel Event Data Root Causes by Event Type: 2004 –2015. Retrieved from The Joint Commission:

(4) The Joint Commission. (2016, 2 9). Summary Data of Sentinel Events Reviewed by The Joint Commission. Retrieved from The Joint Commission:


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