A sentinel event is an unanticipated healthcare setting resulting in either death or a serious physical or psychological injury to either a single or multiple patients (Joint Commission Resources, 2006). The cause is not necessarily associated to natural causes as it is for many other cases of death. It may sometimes lead to a specific loss of a limb or total motor functioning. The result of a sentinel event could carry serious outcomes or even a risk to the patient involved. All sentinel events are identified by Joint Commission on Accreditation of Healthcare Organizations. The revived sentinel (Brent, 2001) which waives some privileges on disclosing confidential information whenever making reports. The sentinel events encourage only the accredited facilities to report are used so as to report only what is necessary and avoid what is not necessary. A sentinel that reports on sentinel facilities reports is passed through accreditation so that only disclosable information is made available.
Disclosing sensitive information breaches the legal rights that a patient has and may lead to prosecution. It is therefore important to perform a root cause analysis of the problem that a patient is experiencing before making a conclusive diagnosis of the problem.
During the root cause analysis stage, there are a number of steps that are followed.
These steps are as outlined below:
The problem is first defined before anything else is done then one prepares to look for possible solutions to the given problem.
Secondly Data collection stage which is aimed at establishing what happened during an interview, document review or during a field observation exercise (Nagelkerk, 2005). The data is collected in a sequence manner such that one can identify the stages and steps followed during that data collection exercise. In an effort to identify the solutions to the said problem, one should avoid the recurrence of the same solutions within the same problem. An individual should also try to avoid causing more problems on top of the existing ones.
The other stage is the data analysis stage which is an interactive process which involves the establishment of failures and successes of the event in question. The event established may have some slight failures which are generalizable in most cases. In carrying out the root cause analysis, it is important to aim at performance improvement rather than the mere treatment of the signs that are caused by the problem (Health Career Information, n.d.). For the root cause analysis to be considered effective it has to be accompanied by conclusions and backed by documented confirmation. This helps in solving the potential root cause of the problem more so when the causes of a given problem are more than one.
Healthcare administrators need to combine the information from sentinel events with Total Quality Management steps in order to achieve the best results in the identification of root cause problems (Hanser, 2010). They should concentrate on the prevention of a problem and not correction of the problem. This reduces chronic wastage of resources on activities that are not beneficial the event concerned. The quality of an event need to be not just continuous but also should be detected in advance.
All risks therefore need to be anticipated well in advance and the problem fixed properly.
There are legal requirements that should be met for a sentinel event to be considered successful. One of the basic requirements is that the sentinel is required to prepare a root cause analysis of the event that is to be undertaken. This is mainly done in order to avoid prejudice in the results that will be obtained in such an exercise.
References
Brent, N. J. (2001) Nurses and the Law: A Guide to Principles and Applications, New York: Elsevier Health Sciences
Hanser Dantex (2010). Total Quality Management. 2010. Web.
Health Career Information (nd) 2010. Web.
Joint Commission Resources (2006).Physicians Promise: Protecting Patients From Harm, Joint Commission Resources.
Nagelkerk, J. (2005). Leadership and Nursing Care Management, New York: Elsevier Health Sciences