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Managing Clinical Adverse Events ( “Sentinel Events” ) Utilizing Intelligent Rule-Based Solutions . Sentinel Event. What is a “Sentinel” Event. No, not this kind of Sentinel. Picture. Sentinel Event . As defined by the Joint Commission

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Managing Clinical Adverse Events (“Sentinel Events”) Utilizing Intelligent Rule-Based Solutions


Sentinel Event

What is a “Sentinel” Event

sentinel event
Sentinel Event
  • As defined by the Joint Commission
    • A sentinel event: Unexpected occurrence involving serious injury, or the risk thereof.
    • “Sentinel” signals the need for immediate response
    • The terms “sentinel event” and “medical error” are not synonymous
    • Not all sentinel events occur because of an error and not all errors result in sentinel events.
sentinel events in alarm management
Sentinel Events in Alarm Management
  • Fall Risk
  • Infant Abduction
  • Patient Elopement (incl. Equipment)
  • Staff Safety (Violent Patient)
why do falls happen
Why Do Falls Happen?
  • Person is weak/ill
  • Reduced Vision
  • Medication (weakness/sleepiness/confusion/dizziness)
  • Slippery/Wet Floors
  • Obstructed Pathways
  • Darkness
root cause identified by organizations and the joint commission
Root Cause Identified by Organizations and the Joint Commission:
  • Malfunction/Misuse of equipment
  • Incomplete orientation of new staff
  • Unavailable or delayed medical care
  • Insufficient education of patients, residents, Inadequate staffing
  • Reduced use of restraints without alternatives
  • Inadequate supervision of caregivers in training
identified risk reduction strategies
Identified Risk Reduction Strategies
  • Adapting “Intelligent” Bed Alarms
  • Installing self latching locks
  • Installing alarms on Bed Exits, Door Exits (Wandering).
  • Adding fall prevention to education of patients
  • Standardizing integration Systems (Connexall/Smartbeds).
  • Using “Low Beds” for those at High Risk of Falls.
  • Revising staff procedures
observed identification of high risk patients
Observed Identification of High Risk Patients
  • “Falling Star” outside of room
  • Wristband
  • Red Socks/Slippers
  • Red Blanket folded on end of Bed

Used to identify immediately and easily

stryker sewsi server protocol
Stryker SEWSI Server / Protocol
  • Stryker’s SEWSI (Stryker Enterprise Web Services Interface)
  • Web Services Interface from Stryker simplifies interface requirements
  • Connectivity via the hospital’s IP network
    • No physical connectivity to the beds is required
    • Represents a vastly simplified physical deployment versus a BedConnex (37 pin connector) design.
bed status alarms
Bed Status Alarms

Available Bed Alarm Conditions:

  • Awareness alarming
  • Bed Exit alarming
  • Bed angle (Fowler 30) alarming
  • Low bed height alarming
  • Side rail alarming (including which side rail is in default).
  • Bed locator module low battery
  • Protocol reminder alarming

Connexall-Specific Conditions:

  • Fall Risk (can be used to validate current Awareness states against established protocols)
  • Ventilator Status (can be used in conjunction with other bed states to generate virtual alarms)

Available Bed Status Conditions:

  • Awareness armed status on/off (including armed state of the following status signals)
  • Bed exit status on/off
  • Brake status (on/off)
  • Bed angle (analog value in degrees)
  • Bed angle above Fowler 30 state
  • Bed supine position state
  • Bed vascular position state
  • Bed height (analog value in inches)
  • Individual bed side rail position (up/down)
  • Current weight on load cell (analog value in lbs/kgs).
    • Note: allows Connexall to qualify all other signals against patient in/out of bed.
  • Protocol reminder set
workflow opportunities
Workflow Opportunities
  • Monitoring real-time state of the bed status signals (i.e. side rail up/down/Brake, etc.)
    • Connexall can derive advanced workflow vs. display and notify of alarm conditions.
  • Proactively enforce fall prevention policies.
    • Each patient assessed for fall risk
      • (ex: low/medium/high fall risk).
    • profile information to Connexall
      • As part of the HL7 ADT data.
      • Retrieved by Connexall from a corporate database system.
      • Manually entered into Connexall by nursing staff.
    • Connexall detects (load cell weight) & allows for pre-qualification of alarm signals.
    • Minimizing alarm fatigue due to erroneous/nuisance alarms
fall risk flow
Fall Risk Flow
  • Automated ADT
  • Manual Updates
  • Risk – Profile
    • If-Then-Else

PV1 Segment

PV1|1|I|5SUR E^500^A|S||......|3^High Risk: Over 50 Pts

FallRisk Update


Smartbed SIC

HIC-Custom Script

fall risk morse scale
Fall Risk “Morse Scale”
  • Patients Continually Assessed
    • Recent Surgery
    • IV added
    • Medication
    • Improvement
    • Patient recently Fell
      • Auto High Fall Risk


modifying fall risk profiles
Modifying Fall Risk / Profiles
  • May Need to Modify the Fall Risk
    • Patient re-assessed
    • Patient needs based on acuity
      • E.g. Hip surgery…..Bed can not be in the “lowest” position.
      • Trendelenburg (Supine) Position.
      • Ventilator
      • Equipment on Foot of the Bed.
  • Patient fall reduction via policy enforcement
  • Profile based risk reminder reduces “sentinel events”
  • Advanced workflow tailored to meet needs
  • Salina Region Health Center:
    • Medical Inpatient: 1st Quarter in meeting / reducing Fall statistics in “recent memory”.

The range of alarm and status events that can be delivered via SEWSI is far in excess of those events available via the 37 pin connector.

    • Reduced physical installation overhead may be offset by more complicated workflow requirements made possible by additional event conditions.
  • Future potential for 2-way communication to Stryker beds/devices.
    • Example: Ability to deliver notifications to InTouch bed, or use its screen as a data entry tool for “virtual callpoints”.