When describing why an event has occurred, you should show the link between your root cause and the bad outcome, and each link should be clear to the RCA Team and others.
Rule 1 - Causal Statements must clearly show the "cause and effect" relationship.The rules are created in response to the very real biases we all bring to the investigation process. The five rules of causation are designed to improve the RCA process by creating minimum standards for where an investigation and the results should be documented. Using the Five Rules of Causation (Adapted for patient safety from: David Marx "Maintenance Error Causation") Some examples of more common adverse events include: patient falls, medication errors, procedural errors/complications, completed suicides, parasuicidal behaviors (attempts/gestures/threats), and missing patient events.
#SENTINEL EVENT DEFINITION JCAHO CODE#
The type of review that the event receives is determined through the Safety Assessment Code (SAC) Matrix scoring process. Adverse events may result from acts of commission or omission (e.g., administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.). Adverse EventsĪdverse events are untoward incidents, therapeutic misadventures, iatrogenic injuries or other adverse occurrences directly associated with care or services provided within the jurisdiction of a medical center, outpatient clinic or other facility. The goal of the Action Plan is to find ways to prevent repeat of adverse events or close calls.
The plan includes outcome measures to indicate that system and process deficiencies are effectively eliminated, controlled, or accepted. The Action Plan addresses system and process deficiencies improvement strategies are developed and implemented. Glossary of Patient Safety Terms Action PlanĪn Action Plan is the result of Root Cause Analysis.
#SENTINEL EVENT DEFINITION JCAHO SOFTWARE#
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