Data helps strengthen the safety program and the culture of reporting. Data is also used to celebrate staff when they are successful. All staff, regardless of position, should be held to the same standards.Įxamine errors: refer to the data compiled and use it to identify the highest risk situations and take action. The organization should also define the types of events that should be reported.Įliminate fear of punishment: ensure that your staff knows that there is no retaliation or punishment for reporting safety concerns. Encouragement also means that staff receives feedback so that they know the action is being taken when reports are made. The four Es of a Reporting Culture include: 3Įstablish trust: there can be no culture of reporting without trust leaders must show their continued commitment to safety and governance should support this as well.Įncourage reporting: this means that reporting is accessible by all staff, easy to use, and delivers data analysis in a timely fashion. Only with reporting will you be able to truly understand the causes of a particular event and prevent similar events from happening again. In order to manage sentinel events, your culture must be one that has adopted reporting. Reporting Is a Key Element of Sentinel Event Management After the standards are implemented, they are closely monitored to ascertain their viability. Following a sentinel event, the organization must begin its investigation by determining root cause analysis, then develop its plan and identify ways to reduce future risk. With the organization’s definition of the sentinel event, it must include the specific events that would be reviewed under the Sentinel Event Policy. Within the Performance Improvement and Leadership chapters of the accreditation manual, there are standards for the expectations regarding the internal identification and management of sentinel events. A reported event is added to the database which other facilities have access to, providing vital information that could help to prevent a similar event from occurring at their organizations. There are benefits to reporting the event that can be of help to other organizations. If the event was due to a medical device defect, then an organization must report the incident to the Food and Drug Administration within 10 days. You can also consult with The Joint Commission on initiating the root cause analysis and action plan. The organization will have to create root cause analysis and an action plan within 45 days of the event. The Joint Commission encourages organizations to report any sentinel event, but it’s not required. An “action plan” should be put in place for potential improvements to decrease the chance of the event happening again. Causal factors need to be analyzed, focusing on the system holistically. Should a sentinel event occur, any accredited healthcare organization must have a process to respond. Standards Must Be in Place to Respond to a Sentinel Event Accredited organizations are required to define sentinel events for their own care system and implement monitoring procedures and a process for root cause analysis. The Joint Commission identifies sentinel events in its accreditation policies to assist with root cause analysis and the development of new preventive measures. The Joint Commission’s mission is “ to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” 2 The Joint Commission defines a sentinel event as an unanticipated event in a healthcare setting resulting in death or serious injury, physical or psychological, not related to natural causes or the patient’s illness. To ensure that healthcare organizations have a high-reliability culture, The Joint Commission Center for Transforming Healthcare published a report, “Sentinel Event Alert 60: Developing a Reporting Culture: Learning from Close Calls and Hazardous Conditions.” 1 The Joint Commission issued this report to encourage a reporting culture where swift action is taken to remedy unsafe conditions. Administrators are too, especially when those actions include reacting to a safety concern raised by an employee. Each staff member is responsible for their own actions. In any healthcare environment, patient safety is always top of mind. Best Practices for Sentinel Events: What Every Healthcare Organization Needs to Know
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |