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Sentinel Event: Not Just a Healthcare Issue

top-ounce-of-preventionDuring my time in the federal health care sector, I became acquainted with the term sentinel event. A sentinel event, according to Joint Commission, is any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.
The Commission’s reporting policy of such, allows the commission to partner with healthcare organizations that have experienced a severe patient safety event. This reporting instrument is designed to protect the patient, improve systems, and prevent further harm.

What are Sentinel Events?

Sentinel events include invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure, unintended retention of a foreign object in a patient after an invasive procedure, including surgery, patient falls, suicides and delay in treatment. As these events occur, process improvement teams are formulated to conduct a Root Cause Analysis. It’s important to note; RCAs are not undertaken to place blame, but instead are used as a problem-solving methodology. The goal is to identify the causes and to simulate its removal to ascertain if a different outcome would have taken place. It’s important to understand that sentinel events are not just all-encompassing of the healthcare industry. Parallels can be found in activities within the cleaning industry. Poor housekeeping, cleaning standards, and or practices can all contribute to a sentinel event in your facility. Practices such as allowing the sight of paper, debris, clutter, and spills; can frequently help to hide hazards that cause more serious injuries.

Not all Chemicals are Created Equal

Moreover, not fully understanding the chemistry of chemicals can also lead to a sentinel event. This understanding lies in words like surfactant, solvent, chelating agent and builder. Understanding a cleaner’s effectiveness against different types of soil is essential to the “Chemistry of Cleaning.” To drive home this point, let’s look at events, such as the influenza and mumps outbreaks in our educational markets. One school’s reaction to such is amazingly a response that most facilities take. I read an article posted on cleanlink.com entitled, “Arkansas School District Cracks Down on Cleaning.” Here’s an excerpt from that article.

“With many confirmed cases of the mumps as well as some cases of the flu in Northeast Arkansas, the Greene County Tech School District is stepping up efforts to sanitize their school buildings. According to Superintendent Gene Weeks, they have purchased extra cases of Lysol products and antibiotic wipes to go to each building in the school district. The district janitors are going above and beyond to prevent the spread of any bugs, Weeks said in the article. “They are cleaning doorknobs, water fountains, light switches, printers,” said Weeks.

Mr. Week’s response, however good-natured, was not based on a clear understanding of the chemistry of chemicals. The cause of Mumps is the Rubulavirus. It is transmitted person to person by drops of moisture from the nose and mouth, such as through sneezing. It can also spread through direct contact with items that have infected saliva on them. Lysol does not provide an efficacy on the mumps virus. However, a failure to implement or follow cleaning standards such as daily disinfecting and sanitizing of high touch areas; is a potential cause leading to the flu and mumps outbreaks in this school district.

Factors that Increase Sentinel Events

Cleaning Programs that have one or more of the following have an increased chance of contributing to a sentinel event in their facility.
• Inadequate assessment of soil type
• No Standard Operating Procedures
• Communication failures
• Human factors such as training deficiencies and knowledge gaps
• No Custodial Management Software Systems in place to properly workload
• Lack of proper cleaning tools and equipment
• No preventive maintenance programs
• No Quality Control Mechanisms
• Lack of Best Practice implementation

It’s important to note that sentinel events manifest themselves within the cleaning industry in a myriad of ways. Events such as slip, trips, and falls, staph infections, MRSA and C-diff can all have a root cause deriving from our daily cleaning practices. One way to mitigate this is by continuous process improvement. Every process improvement team should include cleaning professionals to ascertain every possible source and break down in a facility’s-built environment. Any systemic flaws such as inherent hazards and weaknesses in cleaning programs, can readily be identified by a cleaning professional which can aid in quick solutions to prevent errors from reaching the public and causing harm.

An ounce of prevention is worth a pound of cure

The goal is to prevent all adverse or sentinel events within our industry. This will require facility leaders to recognize cleaning professionals play a significant role in protecting public health. It is critical to provide opportunities for cleaning professionals to learn the science behind cleaning which will better equip them in effectively responding to stain removal, odor elimination, and removal of disease-causing pathogens.

References:
Arkansas School District Cracks Down on Cleaning. https://www.cleanlink.com/news/article/Arkansas-School-District-Cracks-Down-on-Cleaning–20586

https://www.jointcommission.org/sentinel_event.aspx

 

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