Discussion on Healthcare Near Misses and Sentinel Events Analysis

This discussion post delves into the crucial concepts of near misses and sentinel events within the healthcare landscape. It differentiates between the two, defining near misses as incidents that could have caused harm but were averted, and sentinel events as unexpected occurrences leading to patient harm or death. The post highlights the significance of reporting systems in identifying vulnerabilities in care delivery and mitigating potential harm, emphasizing the importance of proactive measures to prevent future adverse events. It references relevant literature, including studies on near misses and adverse event reporting, to support its analysis and underscore the need for continuous improvement in healthcare practices. The discussion also touches on the impact of faulty health management systems and provides examples of near misses and sentinel events. The post concludes by highlighting the importance of reporting near misses and sentinel events, which will not only trigger advancement in weak areas in the care process, but will also alert about gaps and vulnerabilities in care delivery, thus contributing to recovery testing, planning, and harm mitigation.

Running head: DISCUSSION
Healthcare
Name of the Student
Name of the University
Author Note

1DISCUSSION
Introduction- Errors in healthcare are generally defined as failure of planned
procedure to get accomplished as anticipated or the usage of incorrect means for achieving
good health outcomes for all patients.
Discussion- A near miss in healthcare refers to an occasion that might have caused
harm and injury, however, the issue failed to reach the patient owing to timely intervention
by the healthcare professionals or the patient or family members. Also referred to as good
catches or close calls, near misses occur several times, prior to an actual harmful event and
numerous avoidable patient deaths have a history of being preceded by associated near
misses (Bell et al., 2018). A faulty health management system is invariably regarded as the
prime cause for the increase in risk that eventually results in near miss events, and must be
addressed for improving health and safety of all patients. Prescribing medications without
considering allergy history of patients, use of paralyzing drug during operation or wrong-
sided surgeries are some common near misses in hospitals.
In contrast, sentinel events are described as unexpected events that occur in a
healthcare setting, and eventually lead to death of the patient or cause serious psychological
or physical harm to the patients, and are not associated to the natural onset and progress of
the illness of the patient (Paller, Cole, Partin, Carducci & Kanarek, 2017). One example is
fall of inpatient and it typically result in loss of gross motor function or a limb and other
circumstances whose recurrence increases the risk of adverse health outcomes.
Organizational response to both these events focus on the presence of a reporting system that
must encourage the healthcare staff to report about the adverse incidents (Sanko, Kim &
McKay, 2018).
Conclusion- Reporting of sentinel events and near misses will not only trigger
advancement in weak areas in the care process, but will also alert about gaps and

2DISCUSSION
vulnerabilities in care delivery, thus contributing to recovery testing, planning, and harm
mitigation.
References
Bell, A. J., Wynn, L. V., Bakari, A., Oppong, S. A., Youngblood, J., Arku, Z., ... & Goka, B.
(2018). " We call them miracle babies": How health care providers understand
neonatal near-misses at three teaching hospitals in Ghana. PloS one, 13(5).
https://dx.doi.org/10.1371%2Fjournal.pone.0198169
Paller, C. J., Cole, A. P., Partin, A. W., Carducci, M. A., & Kanarek, N. F. (2017). Risk
factors for metastatic prostate cancer: A sentinel event case series. The
Prostate, 77(13), 1366-1372. https://doi.org/10.1002/pros.23396
Sanko, J. S., Kim, Y. J., & McKay, M. (2018). Adverse event reporting following simulation
encounters in accelerated and traditional bachelor nursing students. Nurse education
today, 70, 34-39. https://doi.org/10.1016/j.nedt.2018.08.016