Incident Report Sentinel Events And Root Cause Analysis Essay

Incident Report Sentinel Events And Root Cause Analysis Essay

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Incident Report Sentinel Events and Root Cause Analysis


As a health-care professional, it is understood that the health and well being of a patient is top priority. The dedication to provide care and protection to each patient is ingrained into the very basics of nursing education. However, despite this commitment, medical errors that adversely affect the lives of patients are made everyday worldwide. These types of events are referred to as Sentinel Events. When such an event occurs, there is a need for an immediate investigation and response. This investigation and response is addressed using a methodology called Root Cause Analysis (RCA). With the understanding that mistakes do happen, it is the responsibility of the healthcare system to identify what and why an event has happened with the focus being on making necessary changes to the system.
A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient 's illness (www.jointcomission.org). Other qualifying events include: suicide of a patient within 72 hours after release from a medical facility, discharge of an infant to the wrong family, rape or assault of any patient, staff member, or visitor while in the hospital facility, surgery on the wrong patient or wrong body part, and unintended retention of a foreign object in a patient after an invasive procedure or unexpected death during surgery or within 24 hours after anesthesia begins (on an otherwise healthy patient) (CAMH, 2017). The Joint Commission provides a full list of possible sentinel events on their website.

In 1996, the Joint Commiss...


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... al., 2010). The idea is that human error cannot be eliminated and instead of blaming the individuals, we need to identify and rectify the system weaknesses, which allow human error to cause harm to patients (Taitz, et al., 2010). RCA methodology focuses on three questions: What happened? Why did it happen? What can be done to prevent it from happening again? (Taitz, et al., 2010). In the United States, the Joint Commission requires all healthcare organizations to follow RCA methodology for all sentinel events. Utilizing this methodology and creating a sentinel occurrence database can guide healthcare organizations guided towards areas of concern. The RCA does not concentrate on the individual responsible for the error, but rather how the system itself can be modified and improved to enable the healthcare team an efficient systematic approach to patient care.


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