Take-home points on sentinel events and RCAs 

Reporting voluntary, still have to find them

According to Denise Murphy, RN, MPH, CIC, chief of patient safety at Barnes Jewish Hospital at Washington University Medical Center in St. Louis, infection control professionals should know these key points about sentinel events and root-cause analysis (RCA):

• Unanticipated death or permanent loss of function related to a health care-acquired infection is grossly underreported.
• Any unanticipated death or permanent loss of function always should be considered a sentinel event. All sentinel events should be investigated. Sentinel events are investigated using RCAs.
• All reporting to the Joint Commission on Accreditation of Healthcare Organizations is voluntary. However, the Joint Commission encourages voluntary reporting of RCA results to identify risk factors.
• Though you don�t have to report all sentinel events, you do have to find them and investigate them.