Sentinel Events 2014
Speaker
John R. Rosing, MHA, FACHE
 Accreditation and Regulatory Compliance
Consultant
Vice President and Principal Patton
Healthcare Consulting
262-242-3631
JohnRosing@PattonHC.com
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Most Frequently Reported Sentinel Events,
January 1–June 30, 2013
(Source: 10/13 Perspectives)
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Wrong-patient, wrong-site, or wrong-procedure—60
Unintended retention of a foreign object—56
Delay in treatment†—56
Falls†—48
Other unanticipated events† ‡—40
Operative/postoperative complication†—37
Suicide—35
Criminal event (assault/rape/homicide)—26
Medication error†—20
Perinatal death/injury†—15
– † Resulting in death or permanent loss of function
– ‡ Includes asphyxiation, burns, choking, drowning, and being
found unresponsive
Most Frequently Identified Root Causes for
Sentinel Events, January 1–June 30, 2013
(Source: 10/13 Perspectives)
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Human factors (such as fatigue or distraction)—314
Communication (such as among staff, across disciplines, or with patients)—292
Leadership (regarding, for example, lack of performance improvement infrastructure
or community relations)—276
Assessment (such as patient observation processes or its documentation)—246
Information management (such as patient identification or confidentiality)—101
Physical environment (such as emergency management or hazardous materials)—70
Care planning (planning and/or interdisciplinary collaboration)—49
Continuum of care (includes transfer and/or discharge of patient)—48
Medication use (such as storage/control or labeling)—48
Operative care (such as blood use or patient monitoring)—45
Sentinel Event Defined
• A sentinel event is an unexpected occurrence involving
death or serious physical or psychological injury, or the
risk thereof. Serious injury specifically includes loss of
limb or function. The phrase “or the risk thereof” includes
any process variation for which a recurrence would carry
a significant chance of a serious adverse outcome.
• The terms “sentinel event” and “medical error” are not
synonymous; not all sentinel events occur because of an
error and not all errors result in sentinel events.
RCA Value?
• Root causes vs proximate causes
– The barn door was left open and all the
horses ran away. Close the barn door now –
problem solved
– Mary made a serious medication error, fire
Mary – problem solved
• Could someone else forget to close the
barn door, could someone else make the
same error as Mary?
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RCA Value
• Why was the barn door left open?
– There was no automatic door closing mechanism,
inadequate training, procedural noncompliance
• Why did Mary make the medication error?
– There was no bar coding support, inadequate orientation,
inadequate training, no policy guidance, no secondary
check on calculation
– Procedural noncompliance – Mary duplicated all her
patients wrist bands and unit dose bar codes. Still need to
understand the why, but actions may be different
• Action plan and measurement phase enables you
to redesign for additional safety and monitor
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RCA Value (cont’d)
• Action plan – you create system changes that
help protect against the same error being
repeated
• Measurement – you self assess to determine
if the changes you designed are being used
as anticipated and do they prevent the
weakness you had previously seen. Have
you sustained the improvement??
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RCA Process
• The decision to pro-actively report or not
report to the Joint Commission is
voluntary….
• The decision to analyze or not analyze using
RCA technique is not voluntary under the
standards and SE policy
• If the Joint Commission becomes aware of
your sentinel event, reporting using one of
their techniques, is mandatory
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When To Conduct An RCA
TJC Reportable
All events that meet your internal
definition, including near misses
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RCA Process (cont’d)
• Don’t confuse reporting responsibilities
and deadlines with deadlines for
completing the RCA
– You must complete the RCA within 45 days
of the event, or your becoming aware of the
event
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Do We Ever Skip The RCA?
“It was evident that our problem was a
physician performance issue, should we just
make the referral to peer review and skip the
RCA?”
– Did your system for error prevention work as
designed?
– Did your OPPE, FPPE system identify this
vulnerability?
– Were prior peer evaluations thorough?
– Were privileges granted appropriately?
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What is a Root Cause Analysis?
• A credible process for identifying the basic
or causal factors that underlie variation in
performance.
• This process should be used to identify
the risk that led to a sentinel event.
• Use a RCA framework to drill down to root
cause; complete within 45 days
Starting With The Basics
Define Your Goals
• Your goal: To conduct a complete,
thorough investigation of the event or
near miss
• Why? To ensure you have identified the
real cause or causes of the incident
• Why? So you can prevent this situation
from occurring again
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Starting With The Basics
Getting Organized
Organize your RCA efforts:
– Centralize coordination and oversight
responsibilities to one department
• Allows for better trending of results
• Provides for monitoring to ensure actions have
taken place and results are achieved
– Have a written process for conducting the RCA
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Maintains process consistency
Prevents solution “short cuts”
Ensures important steps are not forgotten
Provides reporting structure and follow up
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Putting Together The RCA Team
Roles and Responsibilities
• Team Leader
– Select wisely
– Usually someone in a leadership position
• Director, manager or higher
– Usually from one of the involved departments
– Should be a strong, fair person who can reign
in group members when needed
– Someone who will not push to solve the
problem before all the facts are uncovered
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Putting Together The RCA Team
Roles and Responsibilities (cont’d)
• Team Facilitator
• Often someone in Performance Improvement,
Patient Safety or Risk Management
• Experienced in facilitation
• Understands how to conduct an RCA
• Can provide “just in time” training for
members
• Familiar with tools such as brainstorming,
Fishbone & Event Flow Diagrams
• Organized
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Putting Together The RCA Team
Roles and Responsibilities (cont’d)
• Team Members
– Rule of thumb keep the group “workable” 6-8
members is ideal
– When possible include those staff/physicians
directly involved in event
• Exceptions– Too emotionally or personally involved
– May be an obstructionist to a good process
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Starting The RCA
Where Do You begin?
• Step one: What happened?
• Identify the key components in the event:
– Who were the people/departments/areas
involved in this event?
– What Equipment, if any was involved?
– What are the key Systems, Processes and
Patient Safety Measures that were involved?
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Gathering The Facts
What Happened?
• Gather the facts- and just the facts. Do not get
bogged down in extraneous details that can
actualize dilute or divert the focus off the key
issues
• Ways to gather the facts include:
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Interviews
Chart reviews
On-line documentation
Event reports
Other data, policies, procedures
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Gathering The Facts
and Just The Facts
– Interview Tips- focus on cooperation not
interrogation
– Chart reviews- documentation and sequencing of
events, create a time line of events
– Event reports- Making sure it is completed with
documented follow up
– Secure equipment- get it before it is gone
– The other “Stuff” you need - policies, procedures,
documents
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How Deep Do You Dig?
• Getting to the root cause is somewhat like
peeling back the layers of an onion until
you reach the core
• A thorough RCA methodically asks the
question “why” until there is no further to
go- until every layer surrounding the core
has been removed and you are comfortable
you have reached the real root cause
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Tools To Help With The RCA
Constructing “What Happened”?
Step two- Begin to put things together
An event flow diagram is a great place to start
putting the facts together
– It is a tool that sequences the steps in the event and
provides you with a chronology of the facts
surrounding the event
– It helps to focus the group on the actual steps in this
event- not how things should occur
– It helps the group identify where there may have been
a breakdown in process that led to the event occurring
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Tools To Help With The RCA
• Let’s walk through a very simplified
example to see how we would create the
event flow diagram
• This is a case of Near Miss in the
emergency room
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Tools To Help With The RCA (cont’d)
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Sequence of Events
– Mr. G, an unaccompanied patient, walked in the Emergency
Room and signed in at the triage desk at 8:45 PM
– Triage nurse was assessing another patient when patient signed in
and did not see patient. Security guard was present at desk
– 9:10 PM Patient with Chest Pain arrived in ED. Triage Nurse
immediately assessed Chest Pain patient
– 10 PM Nursed called for Mr. G. and patient did not respond
– 10:10 Security checked waiting room and found patient
unconscious. Waiting room was full of patients
– 10:11 Emergency Code was called and patient was transported to
treatment bay
– 10:13 Blood sugar found to be 37
– Patient was treated, kept in observation overnight and discharged
the next morning
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Tools To Help With The RCA (cont’d)
• Simplified Event Flow
8:45 Mr. G
Signs in at
Triage
10:11 Code
Called
Pt to TX bay
9:10 PT
With CP
Arrives
At triage
10:13 Mr.G’s
BS 37
10:00 Nurse
Calls for
Mr. G
No response
Mr. G treated
Observed
overnight
10:10 Security
Finds Mr. G
Unresponsive
Mr. G
D/C home in
AM
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Tools To Help With The RCA (cont’d)
• Why did this happen?
• Focus the group on trying to uncover “Why” this
event happened
• Identify all of the “whys”
• Resist the temptation to jump to the solution
• Keeping asking “Why” until you can literally go no
further- there is no additional information to be
gleaned from asking “Why.”
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Tools To Help With The RCA
Brainstorming
• Brainstorming is a great way to surface
potential “Whys”
• It gets everyone involved in process
• Unleashes and uncovers multiple ideassolutions or possible causes
• Can be “free flowing” or “structured”
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Tools To Help With The RCA
Brainstorming (cont’d)
• Free Flowing– Members speak up as they have ideas
– Scribe or facilitator write ideas on flip chart
• Structured– Members are asked to jot down ideas on
sticky notes
– Go around the room using a round robin to
give each member a chance to speak. Keep
going around until no one has any more ideas
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Tools To Help With The RCA
Cause and Effect Diagram
• Constructing a Fishbone or Cause and Effect
Diagram can help the group organize facts
and information into a single picture
– It helps establish possible relationships
– It can help to elicit additional information
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Constructing The Diagram
Organize the results of your “Brainstorming”
into the contributing factors
EXAMPLE:
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Human factors
Equipment factors
Controllable environmental factors
Uncontrollable environmental factors
Other factors
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Constructing The Diagram (cont’d)
• Simplified example of Fishbone or Cause
and Effect Diagram:
Human Factors
Sign in policy
does not ensure
pt is seen before
sitting down
Second triage
nurse on breakrelief nurse did not
show
Equipment Factors
Panic button in
private waiting
room nonfunctional
Other Factors
Environmental
Factors
Private waiting room
design- poor
visualization
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Identify the Root Cause(s)
Prune the list of Root Causes
– Would the problem have occurred if cause
#1 had not been present?
– Will the problem recur due to same causal
factor if cause #1 is corrected or
eliminated?
– Will correction or elimination of cause #1
still potentially lead to similar events?
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Yes = contributing cause, No = root cause
Taking Action
• The Hardest Step In The RCA: Installing
effective error prevention strategies
• Make the right thing to do the easiest
thing to do and then hard-wire it
• Make the process fool-proof
recognizing that nothing is outside the
capability of a sufficiently talented fool! 
Taking Action
Just Do It!!
What can we do to prevent this from
happening again?
• You know what has happened
• You know why it happened
• Now you need to decide what you can
do to prevent this from happening
again
• AND… actually take the steps to make
the changes happen!
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Taking Action
Just Do It!! (cont’d)
• Develop an action plan
– List the Root Causes with the actions needed
to prevent this event from happening again
• Present the plan
– Reporting structure should be established in
your RCA policy- i.e. Patient Safety Committee
• Assign responsibilities for action steps
– These can be assigned prior to reporting to
designated committee or afterwards
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Taking Action
Just Do It!! (cont’d)
• Follow up on assignments
– Usually facilitator or someone in PI, RM or PS
keeps a tracking log
• Report back
– Require follow up to be reported back to
designated committee
• Close the loop
– Monitor for lasting impact
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Taking Action Step
Common Obstacles and Problems
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Fear
Rushing to the solution
Not gathering enough information
Solving the wrong problem
Making tough recommendations
Implementing actions
Doing the follow up- making sure the
changes stick
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Taking Action
• You have completed your RCA
• You have your team’s list of root causes for this
event
• You have drafted your action plan and
measurement strategy
– Who is going to approve the RCA?
– Who is going to approve the action plan?
– Who is going to approve the measurement
strategy?
• This should all be hard coded before you have a
sentinel event
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Importance of Approvals?
• You need people to take action, change
behaviors, change policy, potentially
provide resources and support
• You have a responsibility to measure
change in accordance with your action
plan
– If there is inadequate buy in, your changes
won’t be accepted, your measurement will
not work, your accreditation can be
downgraded and your patients may remain
at risk
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Action Plans
• If your root causes include improper
patient identification techniques…..
– Is it lack of training, orientation, system to
accomplish the technique, procedural non
compliance or failure to provide leadership?
• If your root causes include procedural non
compliance or a failure to lead or fund,
your action plan will be different
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Broad The Scope?
• Your SE involved incorrect patient
identification in cardiac cath lab
• Your root causes identified mis-application
of the 2 identifier technique in cardiac cath
• Your planned actions will focus on cardiac
cath or on your organization?
– Implement actions where ever you have risk,
not just where this event occurred
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Measurement Strategy
• You identify a statistically valid sampling methodology
before starting to measure and you collect audit data
using that system
– Try to collect passively, retrospectively
– Concurrent data collection by responsible staff with new forms may
create under reporting or artificial findings
– Concurrent external observer studies may be more thorough
• You average your 4 months of data and must achieve A
or C level performance or if not linked to a standard 85%
• Be sure to provide rapid, departmental and aggregate
feedback each month and consider graphical analysis to
promote change and improvement
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Building On Success
• Fostering the blame free atmosphere
– Talk about your RCA process, the system
changes, the resources that flowed, display the
improvement data, the enhanced safety
– This can be a positive change experience
• Do analyze procedural noncompliance, was
your design reasonable?
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Root causes, failures, defects,
workarounds, or undesired
variation……
Are usually caused by one or more
of the following……
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Poor process design
Poor transfer of knowledge
Poor validation of competency
Poor measurement of conformance
Poor management intervention
5 Steps to doing the Right Thing Well Sustained
Execution=Continuous Readiness
Measure conformance
• Poor design?
Intervention
(appropriate action)
• Inadequate education
• Ineffective competency
validation
• Variation due to
work-arounds
• Variation due to unit, day of
week, time of day, FT/PT/agency
staff, etc.
John R. Rosing, MHA, FACHE
PI staff
Measure conformance
Staff dev.
Validate competency
Patton Healthcare Consulting
Educate
Focus/PDSA/Rapid
cycle design
Staff dev.
PI team
QUESTIONS?
JohnRosing@PattonHC.com
JenCowel@PattonHC.com
Kurt@PattonHC.com
Please visit and bookmark www.pattonhc.com
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