11/21/2023 0 Comments Nursing sentinel eventsThe primary goal of this study was to assess sentinel event reporting in different mental healthcare settings. Ī review of the current published literature shows a lack of data on comparison of sentinel events between admissions to psychiatric hospitals and admissions to psychiatric units in general hospitals little is known about the associated suicidal characteristics and predictors of suicide among these inpatients, especially in Taiwan. Patient characteristics such as male gender, depressive disorders, violent behavior, history of previous suicide attempts, absence without official leave and the rapid occurrence of suicide after admission are known risk factors for inpatient suicide in psychiatric or general hospitals. Previous reports have indicated that the range of inpatient suicide is 5 to 15 and 100 to 400 every 100,000 admissions to psychiatric and general hospitals, respectively. Suicide occurrence in a hospital setting is one of the most commonly reported adverse events (12.4%), second only to surgical errors about half (52%) of the suicides occur in psychiatric wards. Such a policy must be implemented in accordance with the underlying healthcare system, human activities, work processes, and technical factors that may contribute to the occurrence of sentinel events. Many medical and health service managers have implemented a sentinel event policy to strengthen the reporting, monitoring, and management of major incidents. Such events are called 'sentinel' because they signal the need for immediate investigation and response. The phrase 'or the risk thereof' includes any variation for which a recurrence would carry a significant chance of a serious adverse outcome. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, now the Joint Commission) updated their definition of a sentinel event in 2007 the current definition is as follows: a sentinel event is an 'unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof'. ![]() The terms 'sentinel event' and 'medical error' are not synonymous not all sentinel events occur because of an error and not all errors result in sentinel events. ![]() The delivery of mental health services is very complicated it requires action at all levels of the healthcare organization that is coordinated and integrated in accordance with the principles of clinical governance. In order to improve patient safety, there have been significant changes in the way health services are provided in the hospital setting.
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