Identify the components of risk management incident reports and sentinel reporting
Identify the components of risk management incident reports and sentinel reporting
2. Identify how sentinel events can point to opportunities to improve safety in healthcare organizations.
Purpose: The death of a patient (as described in the Real Life Scenario on pages 233-234) is always classified as a sentinel event. The Joint Commission requires the organization to do a root-cause analysis when such an event occurs. The .purpose of the analysis is to discover what processes led to the occurrence. In this assignment students will use the cause and effect fishbone diagram which is the most commonly used technique used in root-cause analysis. This exercise will give students experience in conducting the root-cause analysis that is used in actual hospital situations.
Assignment Description: Review the Real Life Scenario on pages 233-234 about Dr. Low and his patient Mrs. Yu. Please complete the Root Cause Analysis template attached. There is no outside research required for this assignment.
Parameters: Complete the Root Cause Analysis template and include a cover page that summarizes your findings. Additional directions on how to fill out the template for Root Cause Assignment:
This is a template model for analyzing a sentinel event so not all of the questions will apply to the case scenario that is being asked to analyze.
Columns 1 & 2 (titled Level of Analysis) are just for guidance.
Students should focus on Column 3s Questions answering them in the Findings column 4.
Columns 5-7 for Root Cause/Ask Why and Take Action can be used to indicate whether the findings described in the Findings column are part of the root cause whether we need more information to answer the question or whether we need to take some action.
Students would put a check mark or a Y/N in each box to say whether the findings are part of the root cause/ask why (more info)/take action.
For any Findings that are marked take action in column 7 students should suggest a Risk Reduction Strategy on the last page of the template. Again this is a template so its possible that not every question will apply to the case scenario. You must complete as many of the questions as they can based on the info provided in the case scenario there is no outside research required.Cite textbook reference:
Shaw P. L. & Carter D. (2015). Quality and performance improvement in healthcare: Theory practice and management 6th ed. Chicago: AHIMA. ISBN: 978-1584264750What happened Sentinel Event What are the details of the event (Brief description)
When did the event occur (Date day of week time)
What area/service was impacted
Why did it happen The process or activity in which the event occurred. What are the steps in the process as designed (A flow diagram may be helpful here)
What were the most proximate factors What steps were involved in (contributed to) the event (Typically special cause variation) Human factors What human factors were relevant to the outcome
Equipment factors How did the equipment performance affect the outcome What were the most proximate factors Controllable environmental factors What factors directly affected the outcome (Typically special cause variation) Uncontrollable external factors Are they truly beyond the organization s control Other Are there any other factors that have directly influenced this outcome What other areas or services are impacted
Why did that happen What systems and processes underlie those proximate factors Human Resources issues To what degree is staff properly qualified and currently competent for their responsibilities
(Common cause variation here may lead to special cause variation in dependent processes) How did actual staffing compare with ideal levels
What are the plans for dealing with contingencies that would tend to reduce effective staffing levels
To what degree is staff performance in the operant process (es) addressed Why did that happen What systems and processes underlie those proximate factors How can orientation and in-service training be improved
(Common cause variation here may lead to special cause variation in dependent processes) Information management issues To what degree is all necessary information available when needed Accurate Complete Unambiguous
(Cont d) To what degree is communication among participants adequate
Environmental management issues To what degree was the physical environment appropriate for the processes being carried out
What systems are in place to identify environmental risks
What emergency and failure-mode responses have been planned and tested
Leadership issues:
Corporate culture To what degree is the culture conducive to risk identification and reduction
Why did that happen What systems and processes underlie those proximate factors Encouragement of communication What are the barriers to communication of potential risk factors
(Common cause variation here may lead to special cause variation in dependent processes) Clear communication of priorities To what degree is the prevention of adverse outcomes communicated as a high priority How
(Cont d) Uncontrollable factors What can be done to protect against the effects of these uncontrollable factors Action Plan Risk Reduction Strategies Measures of Effectiveness
For each of the findings identified in the analysis as needing an action indicate the planned action expected implementation date and associated measure of effectiveness. OR. Action Item #1:If after consideration of such a finding a decision is made not to implement an associated risk reduction strategy indicate the rationale for not taking action at this time. Action Item #2:Check to be sure that the selected measure will provide data that will permit assessment of the effectiveness of the action. Action Item #3:Consider whether pilot testing of a planned improvement should be conducted. Action Item #4:Improvements to reduce risk should ultimately be implemented in all areas where applicable not just where the event occurred. Identify where the improvements will be implemented. Action Item #5: Action Item #6: Action Item #7: Action Item #8:
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Step 8: The Risk Team and Legal Counsel Lead the Development of an Appropriate
Insurance Strategy for the Organization
In addition to transmitting information regarding PCEs the risk manager also takes the lead in designing an insurance
strategy that meets the needs of the healthcare organization. To be effective in this area the risk manager must have an
in-depth knowledge of the organization s services facilities equipment procedures and staff capabilities.
The insurance strategy is developed with reference to the healthcare service lines of the organization. For example
the perinatal service is one of the service lines that has the greatest inherent risk of liability. Numerous complications can
occur during a woman s pregnancy labor and delivery and many of these complications cannot be foreseen. The fact
that the organization provides perinatal services would be taken into consideration by the organization s management and
insurer.
Real-Life Example
At Community Hospital of the West Dr. Low an obstetrician delivered Mrs. Yu s infant with relatively little difficulty.
However when the placenta was delivered a rush of blood appeared at the patient s cervical os. Dr. Low attempted to
explore the patient s uterus to see whether there were still pieces of the placenta inside that were causing the bleeding
but there was so much blood that she could not adequately explore the uterus. After several minutes of trying to deal with
the situation she realized that the bleeding did not appear to be abating even though the uterus was contracting
appropriately. Dr. Low decided to take Mrs. Yu to surgery to perform an exploratory laparotomy and possible emergency
hysterectomy. The physician knew that if she could not stop the bleeding the patient s life would be in danger. She
packed the uterus as tightly as possible instructed nursing staff to find blood for a transfusion covered the patient with a
sheet placed the patient on oxygen and began wheeling the patient s gurney to the elevator.
Community Hospital of the West is a major tertiary care facility in a large US city. It has always provided obstetrical
delivery and neonatal services in the north wing of the second floor of the facility. Delivery rooms were developed in this
wing. Surgical services and the operating rooms (ORs) were developed in the north wing on the third floor. When
patients required cesarean section deliveries or other surgical treatment they had to be transferred from the delivery
rooms on the second floor to the ORs on the third floor.
Dr. Low and the obstetrical nurses assisting her waited for approximately one minute before an elevator arrived. Most
of the hospital staff found the elevators very slow and had commented on this many times over the years. Dr. Low the
nurse and Mrs. Yu arrived in about another minute and a half on the third floor and they rushed into an OR. Crash
induction of anesthesia was begun. As the OR staff tried to get a line in to start the blood transfusion and Dr. Low began
to remove the packing from the uterus a massive amount of blood gushed from the organ. The patient s heart went into
ventricular fibrillation and despite emergency resuscitative efforts Mrs. Yu died.
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Because the death occurred during a surgical procedure it was reportable to the county coroner s office. The coroner
accepted the case and performed an autopsy. Mrs. Yu was found to have an anomalous uterine artery that had been
opened upon delivery of the placenta and she bled to death.
QI Toolbox Techniques
The death of a patient as discussed in the real-life example is always classified as a sentinel event. In such cases the
organization should perform a root-cause analysis of the event to discover what processes in the organization led to the
occurrence. There is always the possibility that unusual and unexpected events will occur. No one really could have
known that Mrs. Yu s uterus was anomalous in its blood supply. Does that mean that Mrs. Yu s death was truly
inadvertent Could the death of this patient have been averted despite the anomaly in her anatomy
The toolbox technique used most often in root-cause analysis is the cause-and-effect diagram or fishbone diagram.
This technique structures the root-cause inquiry and ensures that the investigators examine the situation from all
perspectives. As figure 11.7
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Figure 11.7. Sample cause-and-effect diagram
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