Risk Management and Sentinel Event

Risk Management and Sentinel Event Reporting

Explain the basics of Sentinel Event Reporting, including Root Cause Analysis, procedures, timelines, etc.

One of the harsh realities of a medical center or hospital complex or any healthcare facility for that matter is the fact that despite the best effort of healthcare providers, employee and patients get hurt, patients fall down or even commit suicide, fires get started and medication errors occur on a fairly regular basis. In addition, misadventures in surgery and patient abuse occur from time to time, and nosocomial infections arise where no one suspected they would. In this environment, reporting sentinel events represents a timely and important enterprise that can assist a healthcare facility's staff in identifying problem areas so that effective responses can be formulated. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), "A sentinel event is 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. Such events are called 'sentinel' because they signal the need for immediate investigation and response" (Sentinel event, 2008, p. 1).

The standards established by the JCAHO for patient and employee safety are integrated through the organization's standards book and include reporting procedures, the leader's role in safety, failure mode analysis, patient disclosure information, data collection requirements and root cause analysis techniques (Bernsten, 2004). The JCAHO reports that, "Sentinel Event Alert identifies specific sentinel events, describes their common underlying causes, and suggests steps to prevent occurrences in the future. Accredited organizations should consider information in an Alert when designing or redesigning relevant processes and consider implementing relevant suggestions or reasonable alternatives" (Sentinel event alert, 2008, p. 1). As the term implies, "root cause analysis" means examining the potential causes of such misadventures in a thorough fashion to identify potential contributing factors that can be mitigated or eliminated entirely (Gilley & Maycunich, 2000). As these authors point out, "Root cause analysis isolates what is actually creating the performance gap(s). Once isolated, valid root causes become the target of the performance improvement solutions. In essence, eliminating root causes of poor performance allows employees to achieve desired performance, which leads to meeting the organization's goals" (Gilley & Maycunich, p. 201).

2. Discuss the legal implications of Sentinel Events.

According to Sherman (1999), the JCAHO uses sentinel events in order to report situations that could lead to death, serious injury, or the risk thereof -- to determine the weaknesses in existing procedures, systems, and habits. This author also advises that, "The controversy surrounding this aggressive management approach concerns whether such sentinel events will put the organization's accreditation status at risk. Sentinel events need to be reported directly by hospitals so that all may learn and change, rather than waiting for them to appear as scandals in the press" (Sherman, p. 99). The JCAHO emphasizes that, "In support of its mission to improve the quality of health care provided to the public, the Joint Commission includes the review of organizations' activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys" (Sentinel event, 2008, p. 2). The JCAHO also points out that many healthcare providers may be reluctant to report sentinel events for fear of being labeled a "whistleblower" or the potential for retribution by management (Sentinel event, 2008). Notwithstanding this pragmatic rationale, a more important reason to report adverse events in a healthcare setting is the fact that they represent opportunities for improvement and these issues are discussed further below.

3. Discuss how healthcare administrators can combine the principles of TQM/CQI with Sentinel Event Reporting and Root Cause Analysis in developing an effective risk management program.