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Quality and Safety Performance Reports > SE Quality and Safety Performance Reports
 
Sentinel Events

What Are We Tracking And Why? 

We report all sentinel events. A sentinel event is any serious unanticipated event that results in death or serious physical or psychological injury to a patient that is not related to the natural course of the patient’s illness. To best measure, learn from and prevent sentinel events, we adhere to the definition, reporting policies, root-cause analysis, and preventive measures established by The Joint Commission and the National Quality Forum.

Reporting data on sentinel events helps us find ways to reduce the risk of harming our patients during the course of their care.

How Are We Doing? 

We had 1,155,213 outpatient encounters in 2016 and 63,407 inpatient bed days. We had a total of twelve sentinel events. In order to protect the privacy of our patients, and in accordance with 10 USC 1102 and DoDM 6025.13, we are unable to provide further details regarding these events.

What Are We Doing To Improve? 

Patient safety is very important. We are committed to achieving zero preventable patient harm. We employ the following patient safety measures to ensure every patient’s experience is a safe one:
  • TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety), Communication in Healthcare, and Team Huddles are used to increase and improve communication within the care team, and between the care team and their patients.
  • Patient Safety Reporting by staff members at all levels is encouraged and rewarded by our leadership. “Good Catch” awards are given to staff members who identify potential patient safety concerns before they happen. Patient Safety Report Roundups are held monthly to allow staff members to learn about and discuss the actions taken to address patient safety reports.
  • Leadership walk-around rounds are held to enhance staff interaction.
  • Medication Reconciliation is performed to prevent medication errors.
  • Falls prevention education for staff, patients and family members is conducted regularly.
  • Hand Hygiene Protocols are enforced to prevent the likelihood of a hospital-associated infection.
  • Daily Reports are presented to the Director in various public locations within the hospital to allow both patients and staff the opportunity to hear the status of patient safety issues from day to day.
  • Monthly Meetings of the Board of Directors, and the Deputy Directors Council, are held to review our safety and quality of care data.
For each reported event, we conduct a thorough comprehensive review to identify causal factors and develop corrective actions to prevent reoccurrence of sentinel events. Implementing reliable processes helps us improve the safety and quality outcomes for all our patients, and achieve our goal of zero preventable patient harm.

What Can You Do? 

Patients and families are key partners in providing safe high-quality care. We encourage you to bring all concerns to your healthcare team. Empower yourself at each visit by using our Discussion Guide to improve communication with your care providers. When receiving care, remember to ask:
  1. What is my main problem?
  2. What do I need to do?
  3. Why is it important for me to do this?
    (from “Ask me 3”, National Patient Safety Foundation)
For additional information, please contact our Patient Relations Department.

Helpful Resources And More Information 

National Quality Forum’s Serious Reportable Events in Healthcare – 2006 Update
The Joint Commission’s Sentinel Event Policy and Procedures