In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.
An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.
In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. Unfortunately, it was one bag too many; the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal.
The Human Toll
Such sentinel events are all too common. According to a just-released report, Preventing Medication Errors, prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. and kill thousands. The annual cost: at least $3.5 billion. But medication mistakes are just part of the picture.
Sentinel events—unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence—can happen anywhere along the healthcare continuum, in any setting. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function.
Hard-and-fast statistics on sentinel events are difficult to come by, however. Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Researchers cite a number of reasons that many incidents go unreported; among them are lack of time, fear of punishment, and confusion about the severity of events that require notification. For example, do near misses count? (See “Near Misses,” The Hospitalist, May, p. 34.) Others see no benefit to themselves or their institutions from reporting.
Studies have attempted to define the true incidence of sentinel events, but a lack of consistent language and definitions makes it difficult to put the whole puzzle together, even when sentinel events do come to the surface.