Maine Medicine Weekly Update - 04/23/2018 (Plain Text Version)
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24 Maine Hospitals Report Sentinel Events
The 2017 "Sentinel Events Annual Report" states that 34 of Maine's 38 hospitals reported a total of 256 sentinel events in calendar 2017, according to an article from the Maine Hospital Association.
[from the Maine Hospital Association's Hospital Update] Hospitals reported the majority of sentinel events, although another nine events were reported by other facilities covered under the sentinel event law. The number of events reported represents a 13.2 percent increase in reported events from 2016 to 2017, a fact that the Sentinel Event Team (SET) took as due to increased surveillance rather than an increase in events. The report said that 20 percent of the events occurred on a weekend or a holiday. Of the 27 different categories of sentinel events, eight categories made up 83 percent of the total events:
Pressure ulcers have been in the top three most frequently reported sentinel events over the past seven years, the report said. Falls with patient death or serious injury continue to remain the second most reported sentinel event. Reported events show that falls frequently occur when the patient is getting up to use the toilet. The SET continues to see issues, such as the failure to use the surgical timeout process, contribute to continued wrong-site surgeries. The SET questioned if timeouts are being performed accurately and with the required attention. The most common action items from the root cause analysis stemming from these sentinel events are policies and procedures, education and training, and evaluation. The SET plans to focus on the following goals for 2018:
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