Responding to Adverse Events
The Root Cause Analysis (RCA) is a tool used to understand the factors that underlie variation in performance resulting in a sentinel event. This investigation focuses on systems and process variation, over failures in individual performance. The goal of any RCA is to understand the root causes of a sentinel event in order to identify and implement appropriate risk reduction strategies that will decrease the likelihood of recurrence.
The Joint Commission expects the organization to complete a Root Cause Analysis and action plan for all sentinel events. These analyses can be of enormous value because they capture both the big-picture perspective as well as the granular details of the error. Performing an RCA facilitates system evaluation, identification of appropriate corrective action, and tracking and trending of sentinel events.
Talking with patients in the aftermath of an adverse outcome is commonly referred to as “Apology and Disclosure” within the risk management community. It is clinically unique to the specific patient condition and event; however, there are elements that universally apply to the process.
Three core steps in the disclosure process are:
- Recognizing the patient’s perspective
- Understanding the patient’s expectations and align them with the anticipated clinical outcome
- Reconciling the event intellectually and emotionally