![]() ![]() This RCA is fictional and intended only for training purposes. The following is a sample of a Root Cause Analysis in response to a Sentinel Event. 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. ![]() ![]() That would tend to decrease the likelihood of such events in the future or determines, after analysis, that The analysis progressesįrom special causes* in clinical processes to commonĬauses† in organizational processes and systems and identifies potential improvements in these processes or systems A rootĬause analysis focuses primarily on systems and processes, not on individual performance. Including the occurrence or possible occurrence of a sentinel event. Root cause analysis (RCA) is a process for identifying the factors that underlie variation in performance, Natural course of the consumer's illness or underlying condition suicide sexual assault or abduction of a patient. Hour around the clock care setting: unanticipated death or major permanent loss of function unrelated to the The Office of Mental Health (OMH) identifies the following incidents as Sentinel Events, when they occur in a 24 The terms "sentinel event" and "medical error" are not synonymous not all sentinel events occurīecause of an error and not all errors result in sentinel events. ![]() Such events are called "sentinel" because they signal the need for immediate investigationĪnd response. Thereof" includes any process variation for which a recurrence would carry a significant chance of a seriousĪdverse outcome. Serious injury specifically includes loss of limb or function. If, during the course of conducting survey activities, a potential serious patient safety event is newly identified, the surveyor will take the following steps: n Inform the practice CEO that the event has been identified n Inform the CEO the event will be reported to The Joint Commission for further review and follow-up under the provisions of the Sentinel Event Policy Shading indicates a change.A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, The Joint Commission’s Response Patient safety specialists from The Joint Commission assess the acceptability of the practice’s response to the sentinel event, including the thoroughness and credibility of any comprehensive systematic analysis information reviewed and the practice’s corrective action plan. The Joint Commission must receive a request for review of a practice’s response to a sentinel event using any of these options within five business days of the self-report of a sentinel event or of the initial communication by The Joint Commission to the practice that it has become aware of a sentinel event. Interview and review of relevant documentation including, if applicable, the patient’s medical record, to evaluate the following: n The process the practice uses in responding to sentinel events n The relevant policies and procedures preceding and following the practice’s review of the specific event, and the implementation thereof, sufficient to permit inferences about the adequacy of the practic. Further, reporting the event enables the addition of the “lessons learned” from the event to be added to the Joint Commission’s Sentinel Event Database, thereby contributing to the general knowledge about sentinel events and to the reduction of risk for such events in many other practices. ![]()
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