Managing Clinical Adverse Events

Managing Clinical Adverse Events (“Sentinel Events”)
Utilizing Intelligent Rule-Based Solutions
Sentinel Event
What is a “Sentinel” Event
No, not this kind of Sentinel
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
– 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
Fall Risk
Infant Abduction
Patient Elopement (incl. Equipment)
Staff Safety (Violent Patient)
Fall Risk Events
Why Do Falls Happen?
Person is weak/ill
Reduced Vision
Slippery/Wet Floors
Obstructed Pathways
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
Identified Risk Reduction Strategies
Adapting “Intelligent” Bed Alarms
Installing self latching locks
Installing alarms on Bed Exits, Door Exits
Adding fall prevention to education of patients
Standardizing integration Systems
Using “Low Beds” for those at High Risk of Falls.
Revising staff procedures
Observed Identification of High Risk
“Falling Star” outside of room
Red Socks/Slippers
Red Blanket folded on end of Bed
Used to identify immediately and easily
Stryker “Smartbed” Connexall
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
Available Bed Status Conditions:
Available Bed Alarm Conditions:
Awareness armed status on/off (including
armed state of the following status
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
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
• Ventilator Status (can be used in conjunction
with other bed states to generate virtual
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 prequalification of alarm signals.
– Minimizing alarm fatigue due to erroneous/nuisance alarms
Obtaining Fall Risk Information
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
Fall Risk Update
HIC-Custom Script
Fall Risk “Morse Scale”
• Patients Continually
Recent Surgery
IV added
Patient recently Fell
– Auto High Fall Risk
Real-time Bed Status
Real-time Fall Risk Alarms
Intelligent Rule-Based Compliance
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
• Advanced workflow tailored to meet needs
• Salina Region Health Center:
– Medical Inpatient: 1st Quarter in meeting /
reducing Fall statistics in “recent memory”.
Thank You
• 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
– Example: Ability to deliver notifications to InTouch bed, or use its
screen as a data entry tool for “virtual callpoints”.

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