The Joint Commission on Accreditation of Hospitals focuses on hospital-related quality issues. One of their principles involves things called sentinel events. Their definition is “a sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm.”
Whenever such an event occurs, a hospital is required to do what is called a root cause analysis. Its purpose is to “identify system vulnerabilities so that they can be eliminated or mitigated”.
The basic idea is that everything is a process with several steps. If those steps are not followed to the letter, adverse effects can occur. This is similar to the pre-flight checklist that pilots follow.
One of the things that JCAHO has started is something called a time out before a surgical procedure. This is done just before the surgery begins. The surgeon, the anesthesiologist and the nurse must each confirm the facts related to the surgery.
These include the name of the patient, the date of birth, the type of anesthesia, the type of surgery and the instruments to be used.
A good example of this was a surgical procedure recently planned on my son-in-law. He was to have some rods implanted in a surgical procedure. During the time out, they noted they had the wrong rods sent from supply. When they called down to supply, they did not have the correct ones in stock. They canceled the surgery.
My daughter was upset that they had to re-schedule. However, the time out prevented my son-in-law from an unnecessary anesthesia and an unnecessary cutting before they would later discover the same thing.
We know that in medicine there are multiple steps for giving medication. We need the right patient, the right drug, the right dose, the right time and the right route of administration. Things can go wrong at any step.
Readers might remember when I wrote about the bottles of saline and potassium hydroxide that looked alike. Twice nurses washed out eyes with potassium hydroxide instead of saline because of the similarity. The fix was to repackage the potassium hydroxide so the mistake could not occur again.
The point behind all of this is that systems are set up for a reason. The goal might be to prevent an airplane crash. It might be to prevent a wrong site surgery. It might be to prevent a medication error.
It might even be to prevent a fatal shooting on a movie set. Procedures are set up because skipping steps can be fatal. The accident that occurred on the movie set for “Rust” is a prime example of a sentinel event in a non-medical setting.
I fully expect that we will find out that prescribed steps were not correctly followed. I expect that we will change steps so future mistakes do not occur. In essence they will be doing a root cause analysis to prevent future sentinel events.
The JCAHO realizes that processes break down and thus cause problems. You can try and blame an individual. However, human error can be prevented if the correct procedures are put in place and religiously followed. This is as true in things like flying airplanes and movie sets as it is in medicine.
COVID update- The number of new cases nationally remained at about the same level for the third week in a row. Two weeks ago there were 520,000 new cases. Last week there were 511,000. This week there are 513,000. That is less than half of the 1.1 million that we were running at the peak during the summer.
In Sussex County, the number of new cases continued to drop. There were 581 new cases two weeks ago. The number was at 443 last week. This week it is down to 389. That is also less than 50 percent of the 898 high that we experienced during the summer.
Pfizer announced a COVID-19 drug combination. It uses a new drug that falls into the protease inhibitor group and another drug called Ritonavir. Theses types of combinations are used to treat patients with HIV.
In the initial study there were 605 patients treated with the drug. There were 612 patients treated with placebo. There were no deaths in the drug treatment group and 10 deaths in the placebo group. That’s why such a big drop in mortality was announced.
As more people take the drugs, we will get more information. Some of that may be about rare side effects. We will also likely get a better handle on the exact mortality decrease as greater numbers are treated.
At the present point in time the vaccine still remains a more proven approach to addressing the virus.