Patient Safety/Quality Assurance PTCB Test Prep

Sentinel Events and Root-Cause Analysis!

Jul 14th, 2020
sentinel events and root cause analysis

What are sentinel events?

On the PTCB exam, candidates are expected to understand the nature of sentinel events, examples of such events, and what measures – such as root-cause analysis – can be implemented to limit the risk of future sentinel events.

Definition: Sentinel events are events that cause death, permanent harm, or severe temporary harm in the healthcare setting – to either the patient, the staff, or both.

Given the nature of sentinel events, they are not common.

However, sentinel events are important and constitute emergencies and require either immediate treatment and/or investigation – which may, of course, involve law enforcement.

Examples of sentinel events include:

  • A patient committing suicide
  • Unexpected death of an infant brought to full-term
  • Infant being discharged to the wrong person or family
  • Rape or assault of a patient or staff member

All sentinel events must be recorded for analysis. Often, sentinel events must undergo a root cause analysis (RCA); the purpose of which is to analyse the causes of the incident and to implement measures to ensure that the risk of future events is minimized.

In effect, it is about learning from mistakes or ineffective measures that led to the sentinel event in the first incidence.

What is a root cause analysis?

RCA – root-cause analysis – are conducted to find the “root cause” of a problem.

By learning more about how the root cause of a problem (such as a patient suicide) occurred, it informs healthcare professionals to implement measures to ensure that these risks are reduced in the future. In this case, to ensure that healthcare professionals are aware of any deficiencies in the system which allowed suicide to take place when it could have been a preventable event.

Root-cause analyses are not limited to healthcare. This system of introducing measures to prevent a second outcome or repeat of an event is a systemic approach used across many disciplines. In aviation, for example, root-cause analysis helps to identify the specific causes of plane crashes – whether it was pilot error or mechanical failure or an engineering cause – or a combination of all these factors. This detailed analysis of the cause of events allows for the creation of a new set of standards – which are implemented across airlines across the board to maximize the safety of passengers, pilots, and aircrew. The same process applies to healthcare, too – in the prevention of sentinel events. Whilst it is not always possible to predict sentinel events, it is possible to reduce their likelihood in the future.

That is the purpose of any root-cause analysis. It seeks to ask questions such as:

  • Why did the sentinel event take place?
  • What were the contributory factors that created the circumstances for the sentinel event to happen?
  • Who was involved, and why were they involved at the time?
  • Was standard operation procedures (SOPs) complied with, or were they not followed as they should have been?
  • What was the most important causative failure that led to the accident?
  • What preventative measures were introduced at the time to ensure that no repeat of the event could take place?
  • Will these preventative measures be sufficient, or are further, more concrete measures required?
  • How will the results of these strategies be measured? How frequently will this measuring take place and who will implement these measures?

A root-cause analysis of a sentinel event is therefore a detailed examination of the sentinel event. It seeks to identify the causes of the sentinel event, to put in place effective measures that prevent any repeat outcomes, and to measure these newly implemented steps to ensure that they are sufficiently effective over a prolonged period of time.

Final Thoughts

On the PTCB test, candidates may be asked questions about sentinel events and root cause analysis

For example: to identify a sentinel event from a list of 4 possible options. You may also be tested on the definition of a sentinel event. For example, PTCB examiners may provide you with the definition, and from a list of four possible options, you must correctly match the definition with the term.

Alternatively, you may be asked PTCB practice test questions about root-cause analysis – to be able to identify it from a definition or to understand what its function is in the healthcare setting.

Pharmacy technicians are expected to have a broad understanding of these terms and definitions. You are not expected to delve too deep into the theory, history, or background. These topics are mandated for the 2020 syllabus under Patient Safety and Quality Assurance, along with other topics – such as tall-man lettering and drug utilization reviews (DURs).

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