Reducing Sentinel Events Using Patient Whiteboards

Oct 07, 2020

hospital patients

 

The Joint Commission estimates that up to 80% of sentinel events are caused by communication failures, either between those providing treatment or between providers and their patients. These sentinel events cause untold harm to healthcare facilities and especially their patients. They cost lives and money and can tarnish the reputation of a good standing healthcare facility, which is why they need to be addressed and prevented in the most effective way possible. 

Since many sentinel events are rooted in communication errors, this makes hospital whiteboards, useful communications aids, all the more important in hospital settings. 

What Are Sentinel Events? 

 

Sentinel events, as defined by The Joint Commission, is any event in a healthcare facility that results in death, permanent harm, or severe temporary harm of a patient, which then requires life-sustaining intervention. According to The Joint Commission, sentinel events can include everything from falls to surgical errors, medication errors (i.e. incorrect medication or amounts given), delays in treatment, and other patient injuries that occur while in a healthcare facility’s care. 

Studies have shown that sentinel events can result in unexpected additional care, permanent loss of function, temporary and permanent harm, and psychological impacts on a patient’s wellbeing. Each of these cost facilities time, money, and other resources. This is all on top of being a contributing factor in low HCAHPS scores, which can severely limit the reimbursements facilities receive on an annual basis. 

The Major Causes of Sentinel Events 

 

There are numerous causes of sentinel events, and many of them have their roots in communication errors and issues that occur during a patient’s stay in a facility. The Joint Commission identifies the leading causes of sentinel events as: 

  1. Human factors 
  2. Leadership 
  3. Communication 
  4. Assessment 
  5. Information management 
  6. Physical environment 
  7. Continuum of care 
  8. Operative care 
  9. Medication use 
  10. Care planning 

 

Inadequate Hand-Off Communication 

 

Many of these events have their roots in patient transitions, whether between facilities or between providers (Sentinel Event Alert 58 addresses this specifically). During these transitions, mistakes and miscommunications can cause errors in treatmentWhat they call “inadequate hand-off communication” is defined by a receiving treatment team of practitioners getting information that is inaccurate, incomplete, not timely, misinterpreted, or otherwise not what is needed. 

 

How Hospital Whiteboards Aid in Communications and Prevent Sentinel Events 

 

Hospital whiteboards are cost-effective and an easy way to decrease the rates of sentinel events in any healthcare facility that uses them. They are proven to improve communication among care team members and between patients and providers, resulting in more streamlined and effective treatment for patients. 

The Joint Commission has revealed that improving communication is the key to preventing the causes of many sentinel events. Their “Quick Safety” issue on Delayed Treatment highlights that communication is vital. Among their tips are: 

  • Promoting provider-to-provider communication 
  • Making problem lists of the patient’s active and inactive medical problems and diagnoses (a great use for internal whiteboards) 

  • Incorporating diagnostic checklists 
  • Focusing organizational attention on the scheduling process and on ordering tests and reporting tests (see whiteboards for lab settings) 
 
When it comes to preventing falls in a facility, the Joint Commission recommends using whiteboards to educate patients on their risks of falling and how to avoid them. They also recommend setting up internal procedures that notify all staff of fall risks for patients, which can be labeled on patient room whiteboards and on nurses' station whiteboards. 

 

 

When it comes to communication errors, don’t let your patients and your facility be the victim. Contact VividBoard to discover how our whiteboard solutions can make your facility a safer, more organized treatment center.