JCAHO Update for Infection Control: APIC outlines ICP role in sentinel event analysis

The Association for Professionals in Infection Control and Epidemiology recently posted information on its web site to assist infection control professionals (ICPs) in doing a sentinel event analysis.

The information includes these highlights:

What is a sentinel event?

The Joint Commission defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury."

Serious injury specifically includes loss of limb or function. The organization further prescribes a list of reviewable sentinel events as unexpected deaths, unanticipated major loss of function, infant abduction, infant discharged to wrong family, rape, hemolytic transfusion reaction, wrong-site surgery, and patients suicide. Your facility can certainly determine other types of events for which a root-cause analysis is an appropriate investigative and problem-resolution tool.

What is the relevance to your practice as an ICP?

ICPs actively involved in surveillance activities most likely would identify unexpected deaths or unanticipated major loss of function due to infection as a potential sentinel event.

Some of these cases clearly are identifiable but, unfortunately, many are not. Each case has to be evaluated individually.

Use the help of your internal resources to make this determination. The requirement to perform root-cause analyses has been in place for four years. Each facility has a department or person who is responsible for managing this process. Collaboration with an infectious diseases expert, your administrator and medical staff leadership will be valuable resources to you.

What skills do I have to contribute to this process?

The ICP is an extremely valuable member of the patient care team. Your experience with outbreak management and ability to identify infectious events, evaluate likely sources for infection, recognize standards that help prevent transmission or development of an infection, and analyze medical literature make you an excellent resource to the team.

What is my job in a root-cause analysis?

The ICP can participate either as the team leader or a team member. If the ICP accepts the role of team leader, it is important to remember that you are there primarily as a content expert. Carefully listening as participants describe the processes leading to the untoward event is an important skill.

You know what the infection control standards are; therefore, you are the person most qualified to identify gaps or compliance issues. Other team members would include frontline staff most involved in the process, an infectious diseases physician and other appropriate members of the medical staff.

It’s important to remember that these may be very emotionally charged meetings, so the ICP as a team leader should know techniques for defusing sensitive situations.

Warning: It is not unusual for clinicians to debate the clinical management or specific aspects of the case.

For example, did the patient die from the infection or was the cardiac status so fragile that the patient would have expired anyway? While this level of review is important, the peer review committee may be the more appropriate setting for a decision.

The root-cause analysis focuses on systems and processes. The team leader and/or facilitator must skillfully bring the group back to this focus.

In addition, it is important that the message be delivered very early on in the meeting that ALL participants are on equal footing and everyone should contribute.

For many groups, this will be the first time physicians and staff have actually sat in the same room to analyze an event.