Such events are called "sentinel" because they signal the need for immediate investigation and 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. The Office of Mental Health OMH identifies the following incidents as Sentinel Events, when they occur in a 24 hour around the clock care setting: unanticipated death or major permanent loss of function unrelated to the natural course of the consumer's illness or underlying condition; suicide; sexual assault or abduction of a patient.
Root cause analysis RCA is a process for identifying the factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes, not on individual performance.
The following presentation is an introduction to what qualifies as a Sentinel Event and how to conduct a Root Cause Analysis in response to a Sentinel Event. This RCA is fictional and intended only for training purposes. Patient safety solutions are available for immediate review and action by organisations ready to learn and incorporate new knowledge.
This is a neverending cycle necessary for quality and safe patient care today and tomorrow. In support of its mission to improve the safety and quality of healthcare provided to the international community, JCI reviews organisation activities in response to sentinel events in its accreditation process.
The following apply:. Goals of the Sentinel Event Policy. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events. To focus the attention of an organisation that has experienced a sentinel event on understanding the causes that underlie the event, and on changing the organisation's systems and processes to reduce the probability of such an event in the future.
To increase general knowledge about sentinel events, their causes, and strategies for prevention. To maintain the confidence of the public and internationally accredited organisations in the accreditation process.
Accredited organisations are expected to identify and respond appropriately to all sentinel events occurring in the organisation or associated with services that the organisation provides, or provides for. Appropriate response includes conducting a timely, thorough, and credible root cause analysis; developing an action plan designed to implement improvements to reduce risk; implementing the improvements; and monitoring the effectiveness of those improvements.
Reasons for Reporting a Sentinel Event to JCI Although self-reporting a sentinel event is not required and there is no difference in the expected response, time frames, or review procedures, whether the hospital voluntarily reports the event or JCI becomes aware of the event by some other means, there are two major advantages to the hospital that self-reports a sentinel event:.
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Flow charts, affinity charts, or fishbone diagrams can be used to organize information in a visual format. Flow charts outline a process as it is designed as well as how it is commonly carried out. A comparison between a written process and the way it is implemented provides insight into process failures. Fishbone diagrams highlight contributing factors and causes.
Affinity charts organize potential causes. The Joint Commission developed tools, including a RCA framework and action plan template, ensure comprehensive review of the event, and organize findings. After information is gathered and organized, the team starts to identify factors that contributed to the event. Contributing factors are system failures that produce consequences Croteau, They are the causes of the event, although not necessarily the main cause.
The key to the discovery of contributing factors is the question, "Why? When determining contributing factors, discussion needs to focus on outcomes and processes not on individual behavior s. Examine processes to determine if they are inherently flawed or if a variation in the process occurred leading to the event.
All possible contributing factors must be considered. Examples of possible factors include:. Human factors human limitations and capabilities : Human limitations and capabilities such as fatigue, distraction, or inattentional blindness. See Box 1. Patient assessment: Timeliness, accuracy, link to plan of care, documentation, communication.
Organizational culture: Response to risk and safety issues, communication of priorities related to safety, and prevention of adverse outcomes. Members need to participate in conversation analyzing contributing factors.
The importance of exchanging thoughts without criticizing must be emphasized. Whiteboards and flips charts are an excellent way to group ideas and ensure that all team members can visualize information.
Once the team has identified all possible contributing factors, the root cause can be identified. To identify the root cause, the team will drill down the contributing factors until the root cause, or most fundamental causal factor of the event, is determined. Success depends on the team's ability to remain focused on system issues instead of human error. When a human error is involved, the cause of the error must be identified. It is the cause of the error, not the error, which must be corrected to prevent recurrence.
There are many tools available to assist teams. The team starts with listing a contributing factor on a white board. They then ask, "Why? For example, in the case of a wound infection, the team may start with the contributing factor of an unintended retention of a dressing. In this example, it takes many "Whys" before the root cause a delay in documentation is determined. Identifying the root cause may be accomplished by asking three questions Croteau, :.
If the answer to each question is "No," then the team has identified the root cause. In the above example, it is not likely that the clinician would have forgotten to document the count if she had been able to document immediately in the home.
Nor is it likely a similar problem would occur if the root cause were corrected. It is essential that the RCA team does not prematurely stop asking "why," so that the true root cause can be identified. The team may consider whether the identified cause is actionable to prevent recurrence Croteau, If it is, it may be acceptable to stop questioning. Teams must also recognize that more than one root cause is possible. Interactions between root causes cannot be overlooked and may be the actual precipitators of the event The Joint Commission, b.
The correction of one cause does not necessarily mean the recurrence of the event will be prevented. All root causes must be corrected. The root cause statement needs to be succinct. The Veteran's Health Administration n. Action Plans After determining the root cause, the team focuses on identifying strategies to reduce the risk of recurrence. Although the goal is to implement interventions to prevent a repeat of the event, the team must understand that failures and errors do occur.
Design strategies to minimize the risk a process failure will reach the patient and to mitigate the effects of the failure if it does The Joint Commission, Strategies directed at system and process issues, not individual performance or behavior, are most effective in preventing reoccurrence. Actions that are concrete, easily understood, and clearly linked to the root cause or a contributing factor are most valuable.
To avoid work-arounds, make the safest thing to do the easiest thing to do. The plan needs to clearly define who is responsible for implementing each action and a time line for completion. Action plans may include pilot testing.
Determine strategies for measuring the effectiveness of each action. Actions can vary in effectiveness. The National Center for Patient Safety n. Stronger actions are thought to be the most successful. Actions are divided into three categories:.
Once proposed actions are decided, cost, resources, long-term sustainability, and barriers to implementation must be considered.
Buy-in from leadership and those on the front lines who will be impacted is critical. Those assigned individual actions must take ownership. Sharing results of the RCA with leadership is necessary. Reports include a brief description of the event, analysis, the root cause, contributing factors, and the action plan.
Share lessons learned with all staff. Transparency demonstrates that RCAs are not punitive, but a method to change processes and improve patient safety. RCA is an excellent tool for identifying causes of sentinel events. The focus on systems and processes instead of performance brings with it a welcome change from past practices of placing blame on individuals. RCA can be used any time a home care agency has a serious adverse event. See Figure 1.
RCA can also be used proactively to examine near misses. Instead of asking "what happened," the team asks "what might have happened? A year-old female patient was readmitted to the hospital with a wound infection post abdominal excision of a large seroma and delayed primary wound closure. Negative pressure wound therapy NPWT was initiated on January 5 and replaced with a wet to dry dressing prior to hospital discharge on January 8.
Information on packing count was not made available to the agency and there was no follow-up contact with the hospital staff. Later that day, the patient complained that the NPWT system was not functioning. According to the electronic medical record, the wound was packed with six, 4 4 gauze pads, topped with three, 4 4 gauze pads nine total and four large abdominal gauzes pads secured with tape during the interim. The packing count removed, packing placed, and description for this dressing was documented in the clinical note.
On January 9, Nurse 2 removed and counted seven pieces of gauze and packed the wound with white foam, covered with black foam, and initiated the new NPWT system with no documentation of packing reconciliation. Seven pieces of gauze removed did not reconcile with the previous note, but went unnoticed. Once the NPWT was in place, the patient received home visits 3 days a week Monday, Wednesday, and Friday for wound assessment and dressing changes.
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