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Notes 6

These are notes linked to from other pages on this site



In a recent given year, 4.1% of sentinel events in medicine were assault/rape/homicide according to the Joint Commission on Accreditation of Healthcare Organizations.

They also found that medical facility employees proved the least likely source for identifying a sentinel event (less than 1% of the total cases).

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Sentinel Event
According to the Joint Commission on the Accreditation of Healthcare Organizations, (JCAHO, pronounced Jayco) 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. Such events are called "sentinel" because they signal the need for immediate investigation and response, which is exactly the what healthcare organizations do not want (see risk management). They want to appear to be 100% safe and they want to incur no liabilities as a result of preserving evidence or creating records of errors and crimes. People in healthcare organizations are trained to avoid creating records of such events. Systems are organized to defeat even remembering such events.

Root cause analysis (RCA)
Root cause analysis generally is applied to an adverse event that already has occurred and works backwards to find factors that underlie variation in performance. In medicine the current belief is that only systems and processes are the problem and so they ignore variations in individual performance. That is how it is stated in the guidelines of JACHO. "Not individual performance." Since patient safety is run by healthcare professionals, throughout medicine there is a strong disinclination to identify problem personnel or find fault with any healthcare professionals. Some regard this as institutionalizing covering up. Like in the case of Genene Ann Jones and other cases listed in the Table of Contents.

Root cause analysis requires evidence. There is scant little of that for most adverse events because people in medicine will not report them. Medicine is a field in which even the treatments and procedures used often are backed up by little or no evidence to substantiate their effectiveness or their desirability over other options (see Mammosite, for one). In most cases there isn't even long term tracking of patients to see how various operators or procedures effect them. It is a culture that not only is not interested in evidence, but that even has habits and procedures designed to prevent collecting evidence - after all, they repeat, "you have to protect yourself from lawsuits."

According "A Newsletter from the National Patient Safety Foundation," Volume 11: Issue 4, 2008, in an article called "Root Cause Analysis: Are We Looking for Keys Under the Lamp Post?" by Albert W. Wu, MD, MPH, Julius Cuong Pham, MD, PHD, and Peter Pronovost, MD, PHD (all at Johns Hopkins University) "Many people in organizations charged with carrying out RCAs are ambivalent about them. Even if these individuals cannot articulate all of their concerns, they intuitively believe that RCAs may not be cost-effective, or even effective. They also have concerns about the time and effort expended, typically ranging from 20-90 person-hours per RCA."

The full cooperation of the frontline workers is dubious, and according to the article "It is disconcerting that institutions too often seem to experience repeat occurrences of incidents shortly after an RCA is completed."

Two of the things they suggest are in line with chief themes of this web site:
1) An official Patient Safety Organization to serve as a repository of analyses and solutions and with the power to negotiate fixes.
2) The added value of including patient input in the RCA process.

Health care workers will not report most of what goes wrong. It has been demonstrated that patients will report more verifiable information than health care workers when given the opportunity. Health care workers are aware of far more than patients, but will report almost none of it when it is negative. Patients are aware of far less, but will report all of it, in the end reporting a greater quantity of accurate, verifiable information than can be gotten from the health care workers. (See Annals of Internal Medicine article about Unnecessary Patient Deaths)


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Legitimate grievances resulting in suits
Harvard researcher Dr. David Studdert in a 1999 study of 14,700 medical charts found that of the patients who suffered negligent injury, 97% did not sue.

Studdert studied only the legitimate grievances of which there was a written record. If the he had been able to include the number of legitimate grievances of which no record was made, the number of victims who were able to get lawyers would be a small fraction of one percent.

How "no-fault" and blameless can a system be?


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