The Joint Commission (JC) released a new study which provides “better characterization and analysis” of adverse events “that require immediate investigation and response” in ambulatory care settings. These sentinel events, according to the JC, are characterized as unanticipated events that result in patient death or serious physical or psychological injury unrelated to the natural course of the patient’s illness.
In a recent blog post, Gerald Castro, project director for the JC’s Patient Safety Initiatives, reports that wrong site incidents and unintended foreign object retention are the most commonly documented sentinel events in ambulatory care. He notes that wrong site events are more likely to occur when laterality can be confused, specifically during ophthalmologic, orthopedic and dental cases. Needles, sponges, wound packing and broken instrument parts are the most commonly retained foreign objects.
The JC says that 7% of sentinel events documented between 2005 and the first half of 2019 happened at an ambulatory setting but emphasizes that reporting is voluntary, so occurrences may actually be more frequent. In order to prevent reoccurrence, all accredited organizations are strongly encouraged to report any sentinel events.
Ambulatory care facilities are advised to adopt prevention strategies similar to those developed for hospitals, however, the JC recommends that the following differences be considered: patients “may have a chronic illness, but in general have higher levels of medical stability and independence” and there may be more challenges “coordinating care among different doctors.” Based on these variations, the JC says “Patient engagement requires greater consideration when implementing interventions to prevent patient safety events.”
For the Agency for Healthcare Research and Quality’s list of tools and tips on building patient safety programs in ambulatory care, click here.
MLMIC encourages all providers in the ambulatory surgical setting to review the “time out” processes in their facilities to reduce the potential for wrong site surgeries. Additionally, based on the JC’s findings, vigilance in sponge and instrument counts is warranted.
Click here to access more MLMIC resources on effective risk management strategies for ambulatory care setting.