Sentinel event and incident reporting for small clinics

The Joint Commission defines a sentinel event as a patient safety event, not caused by the natural course of the patient's illness, that reaches the patient and results in death, permanent harm or severe temporary harm. WHO's patient safety classification adds the smaller ones: an adverse event reached the patient and caused harm, a no-harm incident reached the patient without harm, and a near miss was caught before it reached the patient.

Near misses are the cheapest lesson a clinic gets, which is why the standards ask for them to be reported too, without blame.

More often than most of us assume. In a US study that reviewed 958 dental records with a trigger tool, 101 adverse events were confirmed, most often pain and infection after treatment. Wrong-tooth extraction made up a fifth to a quarter of the wrong-site never events reported in NHS England, and in one survey about one in five dentists said they had extracted a wrong tooth at some point. In endodontics, separated instruments were found in 3.3% of more than 8,000 cases in one large study, and rates vary widely between studies.

Islamabad (IHRA). The dental MSDS has a standard that sentinel events are assessed and managed, and an indicator that the clinic has listed the sentinel events to watch for; inspectors look for that documented list, incident logs and corrective action records. The GP MSDS asks for an incident reporting system covering medical errors, adverse drug events, needle-stick injuries and falls, for incidents to be analysed for root causes with the corrective and preventive actions recorded, and for near misses to be reported without blame.

Sindh (SHCC). The standards for clinics include the same requirement that the clinic has listed its sentinel events, and ask for incidents and near misses to be reported and analysed to find their causes.

Punjab (PHC). The Minimum Service Delivery Standards are released through a request form, so we haven't quoted them here. Keeping the same kind of register is the safe assumption.

A root cause analysis doesn't need a committee. The Joint Commission's framework comes down to a few steps that work in a two-chair clinic: write down what happened, in order; compare it with what should have happened; look at the contributing factors (people, equipment, environment, staffing, communication); keep asking why until you reach something you can change; choose the strongest fix you can; and check later that it worked. The NHS calls the asking part the five whys.

The fix matters more than the paperwork. "Be more careful" is the weakest kind of fix; a rule that rotary files are single-use in molars, or a checklist read aloud before an extraction, is a strong one.

Open Clinic Management, then Sentinel Events, and press New Event. Pick the event type from the built-in list, which covers the dental events inspectors expect to see: wrong tooth extraction or treatment, jaw fracture during extraction, needle breakage, reamer or file breakage in a canal, a swallowed crown, file or implant part, nerve injury or paraesthesia, a severe drug allergic reaction, tuberosity fracture, and violence against staff or against a patient. Anything else goes under Other.

Then write the description, the patient's name if there was one, when it happened and who reported it, the immediate actions, the root cause analysis and the corrective or preventive measures. You can add up to five photos, such as the radiograph.

Each event moves from Open to Under Investigation to Closed, and a closed event can be reopened. The list filters by status, and the print button makes a report for all events, or the last 30 days, 90 days or 12 months, with your clinic's name, the totals for each status and a table of every event.

The patient's name on an event is free text; it isn't linked to their file, so note the incident in the visit record as well. The register doesn't notify anyone, and photos don't appear in the printed report. The built-in types are dental; a GP clinic can record its incidents under Other, with a clear description.