The Disruptive Physician
Federation of State Physician Health Programs
2010 Annual Meeting
Doris C. Gundersen, MD
Medical Director
Colorado Physician Health Program
Sentinel Events

Defined by The Joint Commission as:
“Any unanticipated event in a healthcare
setting resulting in death or serious physical
injury or psychological injury to a person or
persons not related to the natural course of
the patient’s illness.”
Examples of Sentinel Events
Loss of limb or gross motor function
 Infant abduction or d/c to wrong family
 Unexpected death of full term infant
 Severe neonatal jaundice (bili > 30mg/dl)
 Surgery on wrong patient or body part

Examples of Sentinel Events
Object left in body post operatively
 Rape in continuous care setting
 Suicide in a continuous care setting
 Hemolytic transfusion reaction
 Radiation to wrong area or 25%> than RX

Sentinel Events
Causal Factors are analyzed
 Systems and processes are reviewed
 Individual performance not reviewed
 Root cause analysis performed
 Action Plan for improvements implemented
 Accredited organization reports to JC ≤ 45 days

Advantages of Reporting
Sentinel Events

Contributing to database (track negative trends)

Dissemination of information for prevention

Joint Commission association serves to reassure the
public and demonstrate the priority of patient safety
Joint Commission
In its root-cause analysis of sentinel events,
the Joint Commission traced 70 percent back
to communication failures.
 We have strived to improve patient care
through technology.
 The human factors are also crucial

Joint Commission, Issue 40
July 9, 2008
Defined Disruptive Behavior as a Sentinel
Event
 Recognition that disruptive behavior can:

– Foster medical errors
– Contribute to poor patient satisfaction
– Contribute to preventable adverse outcomes
– Increase the cost of care (including malpractice)
– Lead to turnover/loss of qualified medical staff
Joint Commission

Goal of including Disruptive Behavior as a Sentinel
Event:
– Reform health care settings to address the problem
 There is a history of tolerance and indifference
– Promote a culture of safety
– Improve the quality of patient care by improving the
communication and collaboration of health care teams
Joint Commission Requirements

Hospitals establish a formal Code of Conduct

Leadership creates a process for reporting,
evaluating and managing disruptive behavior
Joint Commission
Recommendations
Educate all team members about
professionalism
 Hold all team members accountable for
modeling desirable behaviors
 Enforce the code consistently and equitably
 Nonconfrontational intervention strategies
 Progressive discipline
