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 analysis progresses from special causes* in clinical processes to common causes†in organizational processes and systems and identifies potential improvements in these processes or systems that would tend to decrease the likelihood of such events in the future or determines, after analysis, that no such improvement opportunities exist.
The following is a sample of a Root Cause Analysis in response to a Sentinel Event. This RCA is fictional and intended only for training purposes. This RCA is documented using a framework created by the Joint Commission. The Joint Commission has many resources related to RCA, including tools such as the framework used here, that can be found on their website www.jointcommission.org
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 consumers illness or underlying condition; suicide; sexual assault or abduction of a patient.
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. 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 organization defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life.
The number of serious patient safety incidents reported to The Joint Commission jumped in 2021, reaching the highest annual level seen since the accrediting body started publicly reporting them in 2007, according to a report shared with Beckers Feb. 22.
The accrediting body received 1,197 reports of sentinel events last year, 89 percent of which healthcare organizations voluntarily reported. In 2020, 809 total events were reported. This total had previously peaked in 2012, when 946 sentinel events were reported.
Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events frequency and long-term trends should not be drawn from the dataset, the organization said.
FAQ
Which example qualifies as a sentinel event quizlet?
What is considered a sentinel event?
What are some examples of sentinel events?
What are the top 10 sentinel events?
- Patient suicide: 382.
- Operative/postoperative complication: 330.
- Wrong-site surgery: 310.
- Medication error: 291.
- Delay in treatment: 172.
- Patient fall: 114.
- Patient death or injury in restraints: 113.
- Assault, rape, or homicide: 89.
