Hospital Quality Improvement and Patient SafetyMarch 30, 2017
What is Root Cause Analysis (RCA)?March 30, 2017
- A sentinel event is an unanticipated occurrence that may involve
- Death or major permanent loss of function unrelated to the patients’ illness or condition
- May occur due to wrong-site, wrong procedure, wrong-patient surgery and
- Signals a need for immediate investigation and response
- Sentinel events may also be serious breaches in standards, processes, procedures, policies or care environment that causes harm, loss, or risk thereof.
Notification of sentinel events is outlined in the Risk Management Program. A suspected sentinel event is brought to the immediate attention of the QI Coordinator and to the Chief of the Department, who decide if a sentinel event has occurred. If it is determined that the event is a sentinel event, a specialized team is assigned to perform a Root Cause Analysis (RCA) and report findings to Medical Management and the Quality Improvement Counsel Committee which implements the recommendations of the RCA to prevent reoccurrence.