Managing Patient Safety Events

Why This Skill Exists

Patient safety events — including adverse events, sentinel events, near-misses, and hazardous conditions — are a fundamental concern of healthcare quality. The Joint Commission Sentinel Event Policy requires that organizations identify sentinel events, conduct root cause analyses, and implement corrective action plans. CMS Conditions of Participation (§482.21) mandate a hospital-wide Quality Assessment and Performance Improvement (QAPI) program that includes patient safety event tracking. The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are publicly reported quality measures tied to reimbursement. State mandatory reporting laws require disclosure of specified events to the state health department. ANA Standard 12 (Quality of Practice) charges nurses with participating in quality improvement and safety activities. Nursing documentation of safety events must be objective, complete, and legally defensible while supporting a just culture approach to error analysis and prevention.

Checkpoint A — Intake Verification

Event Identification

• Event type classified:
  • Sentinel event: An unexpected occurrence involving death or serious physical/psychological injury (Joint Commission definition)
  • Adverse event: An injury caused by medical management rather than the underlying disease
  • Near-miss: An event that could have resulted in harm but did not, either by chance or timely intervention
  • Hazardous condition: A circumstance that increases the probability of a patient safety event
• Patient(s) involved identified and immediate safety addressed
• Witnesses identified
• Time of event and time of discovery documented