Dig for sentinel causes; create effective fixes
Process itself often at fault
By Patrice Spath, ART
Consultant in Health Care Quality
and Resource Management
Forest Grove, OR
A sentinel event is a rare occurrence that results in harm to a hospital patient. The event may cause the patient unnecessarily prolonged treatment or complications. In extreme circumstances, the event may result in anatomical or physiological impairment, disability, or death. Such an event may have been caused by caregivers’ failure to follow routine procedures or by a decision-making error. Because they are so rare, the circumstances surrounding the event should be closely scrutinized to find the root cause. The importance of such analysis is underscored by standards of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, that require "an intense assessment when an important single event occurs" (1997 Comprehensive Accreditation Manual for Hospitals, P.I.4.5).
In high-risk industries where one major incident can impact the lives of hundreds or thousands of people, such as the nuclear energy and airline industries, it is suggested that some form of root-cause analysis be conducted for every occurrence, regardless of severity or complexity. The Joint Commission’s standards do not require such analyses for every important single patient care event. The standards do require that "intense assessment" be done. This intense assessment may lead to a formal root-cause analysis if caregivers agree that a formal analysis of the events leading up to the incident would be beneficial.
The goal of a systematic root-cause analysis of a sentinel event is to identify basic deficiencies or failures in a process, which, if eliminated or corrected, would prevent an event from recurring. Root causes involve both process problems (localized) or problems with the entire system (systemic) that allow or create deficiencies that cause or could cause unwanted occurrences. Root-cause analysis is a rigorous process that uses information gathered during the intense assessment of a sentinel event to determine the underlying reasons for the deficiencies or failures. Many tools and techniques can be used. The process can be made as complicated or painful as you wish, but the simplest, most basic way to find a root cause is to ask "why?" five times (at least). For example:
Quality experts believe that the most common cause of quality problems is the production process itself, not the individuals operating within it. According to this theory, the assignment of responsibility for sentinel events is usually misplaced. While a human error may have occurred, the root cause is likely to be found in the design of the system that permitted it. For example, a physician might fail to follow up on an important laboratory result. While the physician could be faulted, a properly designed system would have prevented this oversight. It’s not enough to fire the staff person who made the mistake or temporarily suspend the doctor who committed the error. In a root-cause analysis, you dig into the processes and underlying systems that allowed or caused the mistake to be made in the first place.
Because it is impossible to eliminate all errors or to design all systems perfectly, patient care processes must be designed to catch errors before they cause harm. One objective of the root-cause analysis is to identify process safeguards that can be put in place to reduce the likelihood of another untoward event. For example, a successful system change aimed at preventing medication errors is computerized checking for prescription errors. An "alert" will appear if a physician writes for a drug to which the patient has a known allergy, or if theophylline is ordered for a patient with a known high aminophylline level.
Evaluate staffing and training issues
When conducting a root-cause analysis for a sentinel event, be sure to look closely at staffing issues. Are people overworked? Are caregivers given responsibilities beyond their capabilities? Are sufficient professional staff overseeing the work of technical staff? If the root-cause analysis suggests that staffing inadequacies contributed to the sentinel event, the investigation team can use their answers to the questions listed below to focus their corrective actions on specific problem areas.
• Are staffing levels appropriate, considering responsibilities, activities, hazards, and schedules?
• Have employees been trained to meet the requirements applicable to the event-related tasks?
• Have agency staff or staff employed by outside companies been trained and qualified on job tasks and hazards applicable to the event-related processes?
• Did the level of staffing, training, or competence affect the proximate or root causes of the event?
• Did the qualifications or training of physicians and staff affect the proximate or root causes of the event?
• Were physicians and staff who were directly involved in the event technically competent to perform their jobs?
• Were the physicians and staff who were involved in the event technically capable of recognizing hazards present in the workplace and responding to eliminate or mitigate the hazards?
• Do management personnel, staff members, and physicians have the necessary levels of education, training, and experience to recognize potential patient care hazards?
• Did lack of knowledge of potential hazards affect the proximate or root causes of the sentinel event?
The apparent cause of a sentinel event may be staff error, but an underlying reason the error occurred could be related to the facility’s orientation or training programs. The investigation team can use the questions below to help them evaluate staff orientation, training, and continuing education processes in hopes of finding root causes that can be eliminated.
• Have training requirements been established for all positions at all levels of the organization?
• Are the training requirements adequate for those positions related to the event?
• Were all training requirements met for those positions related to the event?
• Did the performance of those involved in the event reflect their recorded training?
• Did lack of training or job performance affect the proximate or root causes of the sentinel event?
• Is the content of all training programs based on a task analysis of employee responsibilities?
• How long since staff successfully performed and showed competence in the tasks and activities relevant to the event?
Less than 1 week
1 week to 1 month
Between 1 to 6 months
Between 6 months and 1 year
More than 1 year
Never performed task/activity
• How were involved staff trained for the task or activity?
Classroom lecture
Laboratory training
Guided self-study/computer-assisted
Informal on-the-job training
Structured on-the-job training
Skill learned on previous job at another facility
Skill learned during professional education/schooling
No training provided
• What aspects of the training program contributed to the event? Use the rating scale to rank each contributing factor: 1 = primary factor; 2 = secondary factor; 3 = possible factor.
It should be noted that staffing and training deficiencies are not specific to event-related problems. They represent potential causal factors for ineffective performance of any kind. Resolving staffing and training deficiencies discovered during a root-cause analysis can prevent another unwanted patient care occurrence as well as improve overall organizational performance.
[Editor’s note: In next month’s Quality-Co$t Connection, learn more about the management issues related to sentinel events, including the questions to be answered by an organization’s sentinel event policy.]
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