Factors affecting sentinel events in hospital emergency department: a qualitative study

A sentinel event is an unexpected occurrence resulting in death or serious physical or psychological injury or the risk thereof. The purpose of this paper is to investigate the influencing factors of sentinel events in the emergency department of a military hospital in Tehran to find out some of the effective solutions.

In this qualitative study with content analysis approach, 20 hospital healthcare personnel participated as participants from the fields of medicine and nursing. Purposive random sampling and semi-structured interviews were used for data collection. Atlas.ti software version 5.2 was used for data analysis.

Four themes and 32 subthemes were identified by numerous revisions and combining the codes. The four main themes of sentinel events were: causes, incidence barriers, cause prevention solutions, and barriers’ improvement solutions. Moreover, these main factors were related to these issues: staff and patients’ education, communication, assessment, patients and their companions, employee rights, leadership, care continuum, human factors, physical environment, information management and medication use. Some solutions were also suggested according to these factors and a policy was recommended.

Hospital managers and authorities should try to find the main causes of sentinel events by periodical analysis to find ways to prevent them in the future, using logical and reasonable solutions.

This study confirms that strategies to reduce the sentinel events in emergency departments should focus on empowerment of all staff.