Service Line Development

7466 Words Jul 6th, 2012 30 Pages
Sentinel Event:

Sentinel events are a subset of medical adverse events. Events that require immediate attention are called Sentinel Events. Joint Commission defines a sentinel event as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Sentinel Event identified by Joint Commission also include infant abduction or discharge to the wrong family.

Summary of the Sentinel event in the Case Study:

Sentinel event presented in the case study involves discharge of a minor to
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This root cause analysis team is multidisciplinary, the members being members of the relevant departments, but not involved with the event. A facilitator from the legal office arranges meetings, keeps minutes and writes up the final report.

The charge of the root cause analysis team is to explore all potential causes of the event, sort and analyze these causes, identify risk reduction strategies, and implement a correction plan with a timeframe for completion and monitoring.

The Root Cause Analysis (RCA) is a process for identifying the basic or causal factors that underlie variation in performance. It should focus primarily on systems and processes, not on individual performance. In order to get to the root of the problem, it is important to keep professional skepticism, which requires a questioning mind. The goal is to identify potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future.

In carrying out a root cause analysis, it is helpful to re-create the event with the staff involved in the event.

Root cause analysis team formed to investigate the sentinel event presented in the case study included:

1. Assistant to the Chief Operating Officer 2. General Services Vice President of Security 3. General Manager
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