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Analyze the root cause of a patient safety issue or a specific sentinel event in an organization.
Apply evidence-based and best-practice strategies to address the safety issue or sentinel event.
Create a viable, evidence-based safety improvement plan.
Identify existing organizational resources that could be leveraged to improve your plan.
Analyzing and addressing patient safety issues requires a systematic transition from investigating what happened to implementing sustainable systemic changes. Below is an analysis of a common sentinel event—Medication Errors resulting in severe harm—paired with an evidence-based improvement plan.Analyzing and addressing patient safety issues requires a systematic transition from investigating what happened to implementing sustainable systemic changes. Below is an analysis of a common sentinel event—Medication Errors resulting in severe harm—paired with an evidence-based improvement plan.
A sentinel event, such as a patient receiving an incorrect dosage of a high-alert medication (e.g., Insulin or Heparin), rarely results from a single individual's mistake. A Root Cause Analysis (RCA) focuses on system failures rather than blame.