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Correct Answer: wrong patient, wrong site, wrong procedure
according to the joint commission, the most common type of sentinel events reported between 2004 and 2011 was incidents involving wrong patient, wrong site, or wrong procedure. these types of errors are collectively known as "wrong-site, wrong-procedure, wrong-patient errors" (wspes). these mistakes can result in significant harm to patients, including unnecessary surgeries or procedures performed on the wrong individual or body part.
a sentinel event is defined by the joint commission as any unanticipated event in a healthcare setting that results in death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition. sentinel events demand immediate investigation and response. the classification of an event as a sentinel event is not dependent on the volume of occurrences but rather the severity and the preventability of the errors involved.
the focus on wspes highlights critical issues in surgical and procedural safety. common factors contributing to these errors include communication failures, inadequate preoperative verification processes, and non-compliance with established safety protocols such as the joint commission's universal protocol. the universal protocol, established in 2004, mandates a pre-procedure verification process, marking the surgical site, and a "time-out" immediately before starting the procedure to ensure correct patient identity, correct planned procedure, and correct surgical site.
addressing these sentinel events is crucial for enhancing patient safety and healthcare quality. hospitals and healthcare providers are encouraged to adopt comprehensive risk reduction strategies, including strengthening communication, ensuring strict adherence to safety protocols, and fostering a culture of safety that empowers all team members to actively participate in preventing errors. continuous education and training on these protocols are also vital in minimizing the occurrences of such events.
while wrong patient, wrong site, and wrong procedure errors were the most reported sentinel events during the specified period, other types of sentinel events include suicide, medication errors, and delays in treatment. each type of sentinel event requires specific strategies and protocols to mitigate risks and protect patient safety.
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