Sentinel Event Case - Report Example

Running Head: Sentinel Event Reporting Sentinel Event Reporting of Sentinel Event Reporting Basics of Sentinel Event Reporting Sentinel events are the events that are informed to authorities that have resulted in an unexpected death or serious lasting damage or injury of function not connected to the natural course of patient’s ailment or underlying state. It can be a happening which fulfills the following conditions even if the patient has not been affected drastically: infant kidnap or handed over to the mistaken family, unanticipated death of full term child, critical medical condition causing yellow skin in a newborn child, surgical procedure on the mistaken individual or body part, surgical tool left inside the patient, rape and suicide in unremitting care settings or blood transfusion consequence because of blood group that is denied by the receiver’s immune system(Hutchinson, 2000) . Joint Commission is notified of the sentinel events by hospitals. The commission only recommends that sentinel events be reported by hospitals. It does make reporting to be mandatory for health institutions. Alternatively, the Joint Commission will get to know about the sentinel happening through direct communication with patient, family member, worker at the hospital, surveyor or through media. JCAHO compels that a hospital encountering a sentient event carry out root cause analysis in order to identify and discover the critical or accidental reason of the event (Hutchinson, 2000). Root cause analysis is concentrated chiefly on the techniques and procedures. It advances from exceptional grounds in clinical procedures to communal grounds in organizational procedures and techniques and recognizes possible enhancements in procedures and techniques that are designed the prevent such incidents from occurring. The result of the root cause analysis is the action plan which identifies the plans and tactics that the organization intends to apply in order to diminish the risk of similar happenings occurring in the future (Bartlett, 2003). The plan should concentrate on reliability for execution, pilot testing as suitable, timelines and tactics for determining the efficiency of the actions. The organization is required to prepare a comprehensive and detailed root cause analysis with action plan to be submitted within 45 calendar days of the event to the Joint Commission. The Joint Commission will then decide whether the root cause analysis and action plan are up to standard. If it will be reviewable, the organization will be given additional 15 days to resubmit it again. Upon acceptation, a follow up activity will be assigned due in four months. When carry out the follow up activity, the Joint Commission seeks out to assess the organization’s fulfillment with the valid standards and to score those standards founded on the performance, all the way through the hospital over time. The surveyor identifies a sentinel event, and then he or she is responsible to inform the chief executive about it (Battles, 2001). The chief executive is responsible to report the event to the Joint Commission for additional evaluation and follow up under the Sentinel Event Policy. Throughout the on site survey, surveyor will evaluate the organization’s fulfillment with the sentinel event standards. The survey is conducted in order to implement sentinel event policy to ensure that the same sentinel events do not repeat. Legal Implications of Sentinel Events Sentinel events in legal system promote and compensate the victims of medical malpractice. A criminal investigation follows as soon as there is a sentinel event. Throughout the United States of America, there are portions of law that addresses issues such as the privacy, discoverability and permissibility in proceedings of data pertaining to evaluate patient care. The lawmaking and regulatory surrounding the management of sentinel events is complicated. The Joint Commission recommends most of the health care organization to discard patient or caregiver identifiers when informing the authorities about the sentinel happening (Battles, 2001). The copies of all the root cause analysis submitted in the legal system are not disclosed publicly in order to maintain the reputation of the organization. Also when a team is formed to perform root cause analysis, it is preferable to have access to legal advice. The Joint Commission demands fulfillment with law and regulation. A facilitator from the officially permitted and authorized office organizes meetings, keeps minutes and writes the final report of root cause analysis (Battles, 2001). Root Cause Analysis with Total Quality Management TQM is considered to the management principles and procedures that the management will employ with the entire organization. TQM with RCA will give the amalgamation of culture, attitude of the healthcare organization to give the best product to its entire patient and in creating an effective risk management program. The fundamental responsibility of the healthcare administrator or executive is to deliver clinical care. This head is the main sponsor for developing an effective risk management program and combining the principles of total quality management with sentinel event reporting and root cause analysis. The executive must verify and define the problem but first he or she needs to create a team to work on the problem. The next step is to reach a solution. The team can create its own solution which does have any negative impact, realistic, management support, well-organized, concentrates on root causes. The administrator will use a planned and systematic process to reduce and eliminate the likelihood of the sentinel events that will occur in the specific setting (Hutchinson, 2000) . The first step is to perform root cause analysis by identifying the root causes. These activities are important to successful risk management program using TQM with RCA. After the identification of the root causes, TQM can implemented educational program which will concentrate to increase sensitivity, knowledge and skills to meet the patient’s requirement. The orientation of new employees, ongoing education related to medical-legal and risk management and seminars to target audiences will be included to amalgamate TQM with RCA. The second step which the administrator will take is to identify and take action as soon as the sentinel event occurs by developing plan of action. In this way, activities because of sentinel events will be minimized (Hutchinson, 2000) . The health care administrator will also be responsible for risk financing. For this, he or she is responsible to create a program which will provide coverage to sentinel event. In this way, the principles of TQM can be collaborated with RCA in order to provide an effective risk management program. References: Hutchinson, D. Getting to the bottom of a sentinel event. Am J Health-Syst Pharm. 2000 Bartlett, EE. Physicians cognitive errors and their liability consequences. J Healthcare Risk Manage. 2003 Battles, JB, The attributes of medical event-reporting systems. Arch Pathol Lab Med.2001 . Read More