Becker's Clinical Quality & Infection Control

16 PATIENT SAFETY 7 most common sentinel events this year By Mackenzie Bean C are management incidents were the most common type of sentinel event reported in the first half of 2020, ac- cording to data e Joint Commission released Aug. 12. e commission defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. It reviewed 437 reports of sentinel events in the first six months of the year, 85 percent of which were voluntarily reported to the accrediting body. Despite clinical and operational challenges brought on by the pandemic, the 437 events are comparable to the number of events reported in the first half of 2019. In the first six months of 2020, sentinel events were most frequently reported in the following categories: 1. Care management — 165 reported events 2. Surgical or invasive procedures — 131 3. Unassigned events at the time of the report — 46 4. Suicide — 41 5. Protection events — 38 6. Environment events — 12 7. Product or device — 4 n Ohio board suspends licenses of 2 nurses linked to Mount Carmel patient deaths By Mackenzie Bean T he Ohio Board of Nursing suspended the licenses of two nurses in connection to 2018 patient deaths at Colum- bus, Ohio-based Mount Carmel Health System, reported CBS affiliate WBNS. Wesley Black, RN, and Jordan Blair, RN — who are no longer employed by the system — will have their licenses suspended for one year. Once the suspension period ends, Mr. Black and Mr. Blair will be on probation for three and two years, respec- tively, and have temporary practice restrictions, according to a press release from the Ohio Board of Nursing. Both nurses cared for some of the 35 Mount Carmel patients who died after receiving excessive doses of painkillers be- tween 2015 and 2018. William Husel, DO, a former intensive care physician at Mount Carmel, has been charged with 25 counts of murder in connection to the patient deaths. The state nursing board cited concerns that Mr. Blair and Mr. Black failed to question the high painkiller doses. During the hearing, both men said many nurses trusted Dr. Husel due to his training and anesthesia expertise. Mr. Blair also said that Mount Carmel nurses were "taught to follow the attending physician's orders," according to WBNS. Twenty-two other nurses formerly employed by Mount Carmel are set to have disciplinary hearings with the Ohio nursing board between this July and March 2021. One nurse already has surrendered her license, the board said. n National action plan aims to reenergize hospitals' patient safety efforts By Mackenzie Bean A n expert committee convened by the Institute for Healthcare Improvement created a national action plan to help health systems refocus and reenergize patient safety efforts. The action plan calls for more industrywide collaboration and a larger focus on implementing foundational chang- es to reduce medical errors. The plan shares insights and recommendations in four interdependent areas: • Culture, leadership and governance • Patient and family engagement • Workforce safety • Learning systems The document also includes implementation tactics, case examples, tools and other resources to help health systems make improvements in these areas. The plan comes from the National Steering Committee for Patient Safety, which IHI convened in 2018. The group consists of 27 experts representing federal agencies, safety organizations and patient and family advocacy groups. "The action plan helps direct attention to these interdepen- dent areas, which have substantial, wide-ranging influence on many aspects of patient safety," IHI Senior Fellow Tejal Gandhi, MD, co-chair of the steering committee, and chief safety and transformation officer at Press Ganey, said in a news release. "Accelerating improvement in each of these areas will mutually support improvement in others and create the fertile soil that allows broader safety initiatives to take root and be cultivated." n

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