2. Objective
• To define sentinel event
• To classify type of sentinel event
• Clarify the process of sentinel event.
• Explain Root Cause Analysis (RCA)
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3. Sentinel Event
• An unexpected occurrence involving death or serious physical or psychological
injury or risk thereof.
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Permanent
lost
Wrong surgery
Stress-related
emotional
any process variation for which a recurrence would carry a significant chance of significant adverse
outcome.
4. unanticipated death
• death that is unrelated to the natural course of the patient’s illness or underlying
condition (for example death from a postoperative infection or a hospital-acquired
pulmonary embolism)
• death of a full-term infant
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5. Major permanent loss of function
• Sensory, Motor, Physiologic, or intellectual impairment not present in
admission requiring continued treatment or life style change.
• When the incidence considered Major Permanent loss of function?
1. If patient discharged with continued Major loss of function
2. Two weeks have elapsed with persistent major loss of function
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6. Hemolytic transfusion reaction
• Involving administration of blood and blood products having major blood
group incompatibilities.
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7. Wrong surgery, wrong site, wrong person
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Nosocomial infectious that result in unanticipated death
or major permanent injury.
Unanticipated death of full term infant.
Abduction of infant.
8. Cont.,,,,,,
infant or pediatric discharged to wrong family
Rape
Suicide
Homicide
Any intrapartum maternal death.
Perinatal death unrelated to congenital condition in an infant having a birth
weight less than 2500 gram.
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9. Policy statement (Policy #CQI-4)
• All sentinel event should be reported to executive committee.
• Any time sentinel event occurs, risk management and patient safety
coordinator shall initiate response team which is responsible for complete
throughout RCA.
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10. CQI Departemnt 10
Occurrence Variance shall be submitted to Supervisor
Report to Risk
ManagerFocus Review
Is the event considered sentinel event?
Report Immediately to CQI director to
initiate response team and within 45
days report to MOH and JCI
RCA
report results of RCA
Studying a
process to learn
in greater detail
about how it is
performed or
how it operate
11. What is Root Cause Analysis (RCA)?
• A process used to define, evaluate and systematically analyze “a problem” to
determine the underlying factor(s) or reason(s) for the problem.
• Simply stated, RCA is a tool designed to help identify not only ‘what’ and
‘how’ an event occurred, but also ‘why’ it happened.
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12. Tools to understand RCA
• What happened ?
• How did it happen ?
• Why did it happen ?
• What can be done to prevent it from happening a gain ?
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What can be done to prevent it from happening a gain?
Core principal of
RCA
13. CQI Departemnt 13
Step 1. Step 3. Step 4.Step 2. Step 5.
Define the
problem
Understand
what happened
Identify root
cause
Identify effective
solution
Implement and
track solution
What
happened?
How did it
happen?
Why it
happen?
What can
be done?
Is it
effective
Steps of RCA
14. Step 1. Define Problem (What Happen?)
• “A problem well-defined, is a problem half solved.” Charles Kettering
• Set goal and objectives for the RCA.
• Data collection
• Review documents related to the event: – Medical record – Incident report.
• Interviews those involved
• Observe the “typical” process
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15. For a well-defined problem, identify & describe
• What happened?, what equipment, what method?
• When – when did it occur? Date and time?
• Where – physical location and/or where in the process/procedure?
• How much, how often? – How many times did the incident occur? How
many cases affected?
• who was involved?
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16. Step 2.Understand what happened (How did it
happen?)
• Review the timeline with everyone present.
• Compare actual sequence of events with internal policy/procedures or best
practice according to literature or guidelines.
• Begin to identify opportunities or ideas
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17. Step 3. Determine the Root Cause (Why it
happen)
• What sequence of events leads to the problem?
• What conditions allow the problem to occur?
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18. tools help to identify causal factors
• 1) 5 Whys- Ask "Why?" until you get to the root of the problem
• it is best for simple or moderately difficult problems.
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19. 2. Fishbone
• you can use it to:
• Discover the root cause of a problem.
• Uncover bottlenecks
• Identify where and why a process isn't working.
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20. The manager identifies the following factors, and
adds these to his diagram:
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21. Step 4. Identify effective solution (What can be
done?)
1. Corrective actions: to eliminate the cause and prevent the problem from
recurring.
2. Preventive actions: to eliminate the cause of a potential.
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22. Step 5: Follow up/Monitor
• Monitor results to ensure that corrective actions are effective.
• How’s it going?
• What’s working?
• What’s not working?
• Are corrective actions effective?
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23. • Set time frame
• Must keep good records because………
• If it isn’t written down, it didn’t happen.
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