Avoid panic by planning for sentinel events
Your internal crisis team can smooth the waters
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
A sentinel event is an uncommon occurrence in health care organizations. Because of its rarity, when one does happen it can cause a barrage of urgent and unexpected circumstances that allow little time for caregivers to think, organize, or plan appropriate actions. It is important to have an internal action plan that clearly defines the immediate steps that should be taken when an undesirable event occurs. The action plan should address what happens immediately following the time of crisis, in addition to the steps the organization will take to discover its root cause.
Sentinel event crisis management policies and procedures are not required by standards of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Many of your existing policies and procedures probably contain elements related to sentinel events and incident investigation. It's not necessary to create a separate policy. What's most important is that everyone knows what to do during the time of crisis and what actions will be taken to identify and resolve root causes of the event. If you choose to create a separate sentinel event policy, be careful that it doesn't contain statements that conflict with existing risk management or performance improvement documents.
What to do in a sentinel event crisis
A root-cause analysis is not the first action that must occur when a significant, undesirable patient care event occurs. The time period immediately following the event requires crisis management interventions. (The flowchart on p. 114 illustrates the crisis management phase.) This "panic" phase precedes the root-cause analysis and action planning steps of the sentinel event investigation.
The first priority must be the patient and his or her family. When a serious adverse event occurs, sincere sympathy and compassion expressed to the patient and family is often the most important response to help defuse a potentially volatile situation. The health care team should refrain from castigation or infighting, and rather than taking a defensive stance against accusations of substandard care, immediately begin the following positive measures:
· Assess the situation and communicate with the patient and/or the family.
· Determine who among the health care team will discuss the event, with whom - the patient or responsible family member - and when.
· Maintain contact with the patient and family for questions. Repeated requests for an explanation of the event is a common reaction of angry or anxious patients and family members.
· Organize a family meeting if several relatives are involved in the patient's care or if treatment decisions are complicated.
· Empathize with the patient and family. Offer emotional support. If appropriate, apologize for the patient's distress, without admitting liability.
· Attempt to reconcile opposing perceptions of what has occurred.
Accept responsibility for follow-up of serious complaints, but do not accept or assign blame, or criticize the care or response of other providers.
Individual caregivers will rarely be experienced in dealing with an adverse occurrence. The risk manager and the facility's legal counsel should be available to advise physicians and staff on ways to communicate information to the patient and family in a manner that is forthright and comforting, but that does not unintentionally alarm, misinform, or render judgment.
Document the event
Assign the most involved and knowledgeable caregiver(s) to record factual statements about the event in the patient's record. They also should record what action was taken and any follow-up needed or done as a result of the incident. Avoid writing in the record any information unrelated to the care of the patient, such as "incident report filed," or "legal office notified." Do not erase or obscure information in the patient's record. If a correction is necessary, lightly cross out the original entry, and initial and date changes. Additions to and explanations of notations on the record can be made, for example, to explain issues where professional judgment was involved.
An incident report should be completed by the person who discovers or witnesses the event, or whoever has first-hand information regarding the incident. If staff need help in completing the report, they should be encouraged to seek assistance from their supervisors. Because the incident report is not part of the patient's record, the report can be reviewed and revised until it accurately reflects the event. Incident reports should be forwarded to the risk manager within 24 hours or within the time frame established by the organization.
Although every sentinel event is different, there are some general guidelines to keep in mind - principles and procedures that can be applied to all sentinel event situations:
· Gather as much preliminary information as possible as quickly as possible. Information vital to reconstructing events may be accidentally altered or discarded, preventing determination of cause. The highest priority for the primary caregivers must be the care of the patient, so responsibility for this preliminary data-gathering step must be assigned to others. Typically, the facility's risk manager or quality manager serves as the principal investigator. However, outside of normal working hours, the house supervisor may perform this preliminary investigation.
· Involve legal counsel early in the process. Ask legal counsel for guidance in discussing the situation with the patient and family, how to prevent disclosure of potentially libelous information, and how to handle media relations.
· Some organizations have an identified crisis team that oversees all aspects of the situation in case of a sentinel event. The team comprises clinical and support staff from different parts of the organization having expertise in different areas. In time of a crisis, this team is responsible for immediately taking control of the situation. The team members should be effectively trained and must have the full support and backing of top management to do their job.
· If it is likely the event will become public knowledge, have the public relations department draft an immediate written statement for the media with approval from legal counsel and the CEO. Include the facts that are known about the event and the organization's responses if they have been determined. Anticipate questions that will be asked by the media, and try to answer these in the statement. Issues mostly likely to be raised by the media include: Who or what is the cause of the sentinel event? What is the extent of the patient's injuries? What is the organization's immediate and long-term response to the event? Has this or a similar patient incident happened before in your facility? (General guidelines for handling the media following a significant patient care event are listed on p. 115.)
· If a media spokesperson has not already been named, decide who it will be. That may be the CEO or another authority figure within the organization. In case of unavailability of the CEO, a next in command should be named by the Board of Directors. Have only one spokesperson if possible. It is important to have one voice that helps the public understand what really happened, what is being done to correct the situation, and what steps are being taken to avoid future events of this type. Maintain accurate logs and records of all inquiries about the event and keep written records of all statements, releases, newspaper articles, and broadcast reports. This will help the organization's leaders evaluate the extent and tone of the publicity. It also will help the leaders evaluate their own response after the crisis has subsided.
Your plan should be spelled out on paper. All managers and supervisors should know what this plan is and what their individual responsibilities are. Be sure to define each step, how it will be handled, and who is responsible. Make a list of all the key people within the organization that need to be contacted in case of a sentinel event, and include their contact numbers. (See contact list, p. 116.) The list should be updated periodically and should be accessible to managers, supervisors, and members of the crisis management team if a team approach is used. The list also can be used to document the contact results - what time the person was reached, what course of action they recommended, and what role the person is going to play in the crisis management phase.
Another list of names and numbers of key people outside the organization should be maintained as well. This list will have contact information for members of the media, relevant agencies, and relevant authorities.
Periodically evaluate crisis preparedness
Remember that a sentinel event crisis management plan is a work in progress and must be modified, adjusted, and updated periodically. If your organization has the unfortunate opportunity to test your sentinel event crisis management plan, all elements should be analyzed to determine the effectiveness of each step in resolving the situation while keeping media portrayals of the facility in the best possible light. This evaluation should begin as soon as possible after the immediate crisis has been resolved. The evaluation may include conducting interviews with internal physicians and staff. If the event becomes publicly known, analyze the content of newspapers and broadcasts to assess how your organization's image is portrayed by the media. Modify the plan where the needs of the situation are not met effectively.
Suggested reading
Medical Group Management Association. Crisis Communication Plan. Available from Dennis L. Barnhardt, MGMA Director of Communications, (303) 397-7870, [email protected].
Cooper JB, Cullen DJ, Eichhorn JH, et al. Administrative guidelines for response to an adverse anesthesia event. J Clin Anesth 1993; 5:79.
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