A Self-Assessment Guide for Health Care Organizations - IFC

Standard QMI.5 [Sentinel events]
The organization uses a defined process for identifying and managing sentinel events.
Intent of QMI.5
The organization’s definition of a sentinel event includes events as may be required by law or regulation, and those viewed by the organization
as appropriate. All events that meet the definition are assessed by performing a credible root cause analysis 50 . When the root cause analysis
reveals that systems improvements or other actions can prevent or reduce the risk of such sentinel events recurring, the organization redesigns
the processes and takes whatever other actions are appropriate to do so. It is important to note that the term “sentinel event” does not always
refer to an error or mistake, or suggest any particular legal liability.
Measurable Element Look for Score Observations
What is required
1) The organization has
established a definition of
a sentinel event that
includes at least:
a. unanticipated death
unrelated to the
natural course of the
patient’s illness or
underlying condition;
b. major permanent loss
of function unrelated
to the natural course
of the patient’s illness
or underlying
condition; and
c. wrong-site, wrongprocedure,
wrongpatient
surgery.
2) The organization has
a process by which it
identifies high-risk areas
in terms of patient and
staff safety.
3) The organization’s
leaders undertake a formal
assessment of patient and
staff safety risks at least
once per year.
How is this element
assessed
A policy/procedure defines
“sentinel event” and includes the
required elements. Documents
show that a root cause analysis was
done and actions taken to respond
to a sentinel event. (As these events
do happen in hospitals all over the
world, it would be unlikely that a
hospital did not have a record/
history of sentinel events.)
A policy/procedure describes a
process for identifying high risk
areas/processes, e.g. pro-active risk
assessment. Plans, minutes of
meetings and reports demonstrate
that the organization has identified
potential risks and taken proactive
actions to reduce them.
Minutes, reports or other
documents show that the
organization has conducted a
formal assessment of risks and the
management of risks on an annual
basis.
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50
UK National Patient Safety Agency. A Guide to Root Cause Analysis. Available at: www.msnpsa.nhs.uk/rcatoolkit/course/iindex.htm
54 IFC Self-Assessment Guide for Health Care Organizations