Problem: An avoidable unfavorable outcome of medical treatment is considered of health care-acquired conditions (HACs). It is described as the "use of the wrong plan to achieve an objective or the failure of a planned action to be completed as intended." (Donaldson, Corrigan, Kohn, 2000) Risk management plans are usually a result of these avoidable health acquired conditions such as catheter related urinary tract infections.
A sentinel event or "never event" is an unanticipated incident that involves death, significant injury, or the potential for either. This unexpected event causes death or significant irreversible loss of function that is unrelated to the patient's sickness or underlying condition(s). Sentinel incidents can be anything from a blood transfusion response to performing surgery on the incorrect patient or body area to accidentally implanting a foreign object during surgery. They serve as sentinels because they alert authorities to the need for an early investigation and system improvements to stop a repeat of the incident. (Pozgar, 2013)
There are various ways my current employer tries to prevent these "never" events. The major one that comes to mind is in-patient suicide. In order to prevent this, we utilize suicide screening tools on every patient that comes into hospital. If patient is at an increased risk for suicide, suicide-specifically hospital policies and procedures are put into place to prevent this like removing all objects and cording in room, serving meals with paper utensils and having a 24 hour sitter in the room with them.