Sentinel event: an occurrence unplanned, not scheduled or anticipated, resulting in death, serious harm, or the risk for physical or psychological harm.  This includes rape, infant abduction, and suicide where observation was intended to be in place.

“Near misses”: would have resulted in sentinel event if chance or intervention had not occurred.   

Adverse event (AE): an event caused by the medical treatment or management that was not anticipated or planned during the medical care of a patient. Adverse events can be preventable or unpreventable.  Adverse events can lead to a sentinel event.

Example of preventable adverse event:  60 y/o patient is admitted on Prozac, 40 mg qd; for depression. Prozac is continued. Patient also has a cough and pain. Ultram and Dextromethorphan are added. The patient develops serotonergic syndrome due to drug interactions.

Example of unpreventable adverse event: Patient is having a surgical hip replacement.  Prior history for hypertension was noted and steps taken by the family practice physician to decrease any adverse complication during the surgical procedure.  In spite of all interventions correctly instituted, the patient incurred a cerebral vascular accident while under anesthesia. 

Adverse Drug Event (ADE): death or injury from a wrong medication, or wrong dosage, or from multiple pharmaceutical interactions/reactions.

Root Cause Analysis (RCA): a process to study a situation, circumstance, or problem in a prescribed method to allow actual determination of the primary (root) cause in a sequence of events. RCA requires an investigation/review, collaboration, an action plan, implementation process, and follow-up for monitoring the corrective action results.

Overuse, under use, misuse as defined by the IOM Committee:

Overuse:  providing medical care that’s use has potential for more harm than good. 

Chapter 4 Example: utilizing overuse of antibiotics for viral infections in the pediatric population

Under use: not providing a medical intervention that could have been helpful to the patient. 

Chapter 4  Example: not following core measures for AMI (e.g., use of ASA and Beta Blockers.

Misuse: an intervention is scheduled but a preventable complication occurs and the intervention is not given the opportunity to work.

Chapter 4 Example: A patient is scheduled for surgery for bowel obstruction.  He is to be NPO (no oral intake) 8 hours prior to surgery.  Communication is lax, an error occurs and the patient is given breakfast.  Before the next 8-hour NPO time frame is met, the patient’s intestine ruptures. He is rushed to surgery.  The abdominal cavity contamination results in peritonitis and the patient does not recover. 

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