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Sentinel Event TRAUMA- Root Cause Analysis HELP Nomoreerrors.com

April 19, 2012

Quotes from: http://www.nomoreerrors.com/unique.htm

Shock of a Sentinel Event  “When a sentinel event occurs in a healthcare facility, the organization is frequently paralyzed by the trauma of the event. It becomes difficult to appropriately focus on finding out what happened and what they need to do to prevent such an event from occurring in the future. Beyond the shock that accompanies the event, not surprisingly, most organizations lack the proper knowledge, experience and insight to be able to respond appropriately to the event because they are rarely faced with such a situation.

Root Cause Analysis

When a medical error occurs in a health care organization, it is necessary to investigate and understand the causes that underlie the event. The organization’s systems and processes require change to reduce the probability of such an event in the future. Root cause analysis (RCA) is a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a medical error. A root cause analysis focuses primarily on systems and processes, not individual performance. It progresses from special causes in clinical processes to common causes in organizational processes. It identifies potential improvements in 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.  Public accountability

Public Accountability  

Healthcare organizations have a moral and ethical responsibility to provide safe care to the public. By creating safer healthcare organizations, Critical Management Solutions can help you fulfill this public accountability and be responsive to regulatory and accrediting bodies.”

 

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