Team Approach to Sentinel Event Response

To be effective, balance leadership and team focus

Here’s how to educate staff on their roles

(Editor’s note: The following article is the second in our two-part series on taking a team approach to sentinel event response. The first article in the series, included in Hospital Peer Review’s December 1999 issue, focused on how to set up an effective sentinel event response team. Part two focuses on how the team can best respond to the challenge of formulating a thorough response once a sentinel event has occurred.)

While it’s crucial to develop a team approach to sentinel event response, it’s equally important to understand the need for effective leadership, experts say.

"We recommend that either the risk manager or the quality director or both lead the team," says Nancy Lima, MBA, BSN, CPHQ, FNAHQ, director of performance improvement at Denver-based Catholic Health Initiatives. "They’re familiar working with sentinel events, the [Oakbrook Terrace, IL-based] Joint Commission on Accredi ta tion of Healthcare Organizations [JCAHO], and knowing what constitutes a thorough and credible root-cause analysis," she says.

Having the roles of the various team members well-established before a sentinel event is reported is crucial, Lima adds, because once a sentinel event situation arises, things begin happening quickly.

Development of a thorough and credible root-cause analysis should begin shortly after the event is identified. According to the Joint Com mission, that means determining which human and other factors, processes, and systems were closest to the event; establishing that leadership participated closely in formulating the analysis; explaining all inapplicable findings; and drafting an analysis that is internally consistent and that considers relevant literature.

Once you’ve identified what the root causes were and what factors contributed to the sentinel event, it’s time to develop an action plan and determine what needs to be fixed. That may involve designing an entirely new process, or it could mean simply adding some new components to existing procedures, says Terri S. Karsten, JD, associate counsel for provider operations at Catholic Health Initiatives.

In some instances, the solution may be so obvious that changes can be implemented immediately without the need for lengthy discussion among the response team members. For example, Lima cites a situation that occurred at a hospital several years ago in which a medication error resulted when a staff member administered IV Hespan instead of IV Heparin.

"They realized that [the error] always happened when it was busy in the intensive care unit," Lima says. "Your mind is full if you are busy and go to get the IV bag with the big red label with the big black letters that say Heparin; it’s very easy to pick up a bag that looks exactly like it with a red label and black letters that say Hespan. [The team] realized that the bags looked too similar and needed to be better differentiated, so they changed the color of the labels and they never had that incident again. They didn’t have to go through lots of brainstorming and continuous quality improvement and analysis to come up with that. Once the team looked at the procedure, it was clear that a simple change could be made right away to prevent further occurrences."

Unfortunately, not all problems are so easily rectified. "If you have a more complex sentinel event that requires more complicated policies or procedure changes, those issues involve not only detailed analysis but also input and support for leadership, and they occur over a much longer time frame," Karsten says.

Also, some problems that appear easy to fix may in fact be symptoms of larger systemic problems, Lima adds. "You may happen to notice the piece that’s broken, but you may need to look at a larger system, such as how you credential your medical staff or how you assess the competency of your staff in general, to see if it is flawed," she says. And when it comes to addressing those larger systems, if you don’t have the support and active involvement of leadership, fixing the problem becomes extremely difficult.

"You need to have someone with the clout to make some of those larger system changes, such as allocating resources to invest in new equipment or new programs," Lima says. "When we’re talking about a sentinel event in an organization, [leadership] needs to have an understanding of what’s happened and what’s being done to fix the problem and keep it from happening again."

Staff education streamlines processes

Another important factor in responding effectively to sentinel events is staff education. Every one in the organization should have at least a broad-based knowledge of what a sentinel event is and how it should be reported to appropriate personnel. That sort of general information can be supplied at orientation meetings for new employees and at annual "refresher" inservices for existing personnel.

"Clearly, the employees who may be involved need to know how to report sentinel events as quickly as possible, because you need to start the investigations and analysis quickly to be able to determine the root causes in the given time frame and decide whether to report to the Joint Commis sion and protect all the information," Karsten says. "A lot of things need to happen almost immediately after the event occurs. So, everyone having a baseline knowledge of sentinel events and recognizing the importance of notifying the appropriate personnel is going to be key."

Educating staff about how the organization responds to sentinel events is important for another reason as well, Karsten notes. "These are individuals who could report information directly to the Joint Commission if they don’t feel it was handled appropriately internally," Karsten says. "You want all members of the organization to know that you take sentinel events seriously when they are reported and to understand the process that you follow."

(For a checklist of the components of a hospital sentinel event policy, see p. 11.)