________________________________________________ Medical Error Prevention and Root Cause Analysis
– Any elopement (i.e., unauthorized departure) of a patient from a staffed around the-clock care setting (including the emergency department), leading to death, permanent harm, or severe temporary harm to the patient – Discharge of an infant to the wrong family – Rape, assault (leading to death or permanent loss of function), or homicide of any patient receiving care, treatment, and services – Rape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the healthcare organization – Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (e.g., ABO, Rh, other blood groups) – Invasive procedure, including surgery, on the wrong patient or wrong site – Unintended retention of a foreign object in a patient after surgery or other invasive procedures – Severe neonatal hyperbilirubinemia (bilirubin >30 mg/dL) – Fluoroscopy resulting in permanent tissue injury when clinical and technical optimization were not implemented and/or recognized practice parameters were not followed – Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care – Any intrapartum (related to the birth process) maternal death – Severe maternal morbidity – Fall resulting in: any fracture; surgery, casting, or traction; required consult/management or comfort care for a neurological or internal injury; a patient with coagulopathy who receives blood products as a result of the fall; or death or permanent harm as a result of injuries sustained from the fall (not from physiologic events causing the fall) Alternatively, the following examples are events that are NOT considered reviewable under the Joint Commission’s sentinel event policy [6]: • Any close call (“near miss”) • Full or expected return of limb or bodily function to the same level as prior to the adverse event by discharge or within two weeks of the initial loss of said function, whichever is the longer period • Any sentinel event that has not affected a recipient of care (e.g., patient, individual, resident)
ROOT CAUSE ANALYSIS PROCESS The Joint Commission is a national organization with a mis- sion to improve the quality of care provided at healthcare insti- tutions in the United States. It accomplishes this mission by providing accredited status to healthcare facilities. Accreditors play an important role in encouraging and supporting actions within healthcare organizations by holding them accountable for ensuring a safe environment for patients. Healthcare orga- nizations should actively engage in a cooperative relationship with the Joint Commission through this accreditation process and participate in the process to reduce risk and facilitate desired outcomes of care. Root cause analysis, as defined by the Joint Commission, is “a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or pos- sible occurrence of a sentinel event” [6]. In the 2022 update, the Joint Commission defines a sentinel event as a “patient safety event (not primarily related to the natural course of the illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm)” [6; 10]. Furthermore, the Joint Commission revision clarified the terms “severe” and “permanent” harm with regard to sentinel events. “Severe harm” is an event or condition that reaches the individual, resulting in life-threatening bodily injury (including pain or disfigurement) that interferes with or results in loss of functional ability or quality of life that requires continuous physiologic monitoring or a surgery, invasive procedure, or treatment to resolve the condition [6; 10].“Permanent harm” is an event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline [6; 10]. The following subsets of sentinel events are subject to review by the Joint Commission [6; 11]: • The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition or • The event is one of the following (even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patient’s illness or underlying condition): – Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge – Unanticipated death of a full-term infant – Abduction of any patient receiving care, treatment, and services
15
MDFL0626
Powered by FlippingBook