June 13, 2006

Medical Malpractice Essentials: Sentinel Event and Root Cause Analysis

If you have handled medical malpractice cases in and around Kentucky you have no doubt practiced a case with Kirsten Daniel. She spent the last 8 years defending doctors and hospitals in Kentucky medical malpractice cases and gained extensive trial experience in the process. I am pleased and proud to say that she recently made the switch from the dark side and joined our firm.

On our way to meet with clients yesterday, Kirsten and I started talking about Sentinel Event and Peer Review materials and their importance in med mal litigation. She informed me that many plaintiff's lawyers don't even request Sentinel Event or Peer Review materials, which came as a big surprise to me. I can only assume this is because these lawyers don't know about the JCAHO's Sentinel Event policy. And that is a big problem, as these materials often contain a wealth of information which is not discoverable by any other means.

It is essential that any lawyer handling medical malpractice cases have a firm grasp of Sentinel Event, Root Cause Analysis and Peer Review procedures. The JCAHO website is a great place to start educating yourself on the subject.

Sentinel Event Links

Joint Commission Sentinel Event Main Page

Sentinel Event Policy and Procedures - Joint Commission

Joint Commission website search for "Sentinel Event"

JCAHO Sentinel Event Flow Chart

Here are two books which should be in the library of any medical malpractice lawyer:

Sentinel Events: Evaluating Cause and Planning Improvement, Second Edition

Root Cause Analysis in Health Care: Tools and Techniques, Third Edition

May 30, 2006

For the Kentucky Medical Malpractice Lawyer: Motion to Compel Sentinel Event and Peer Review Materials

Kentucky medical malpractice attorneys: Do you request sentinel event and peer review information in all your medical malpractice cases? You should.

All hospitals eligible for federal funding are accredited by the Joint Commission on Accreditation of Healthcare Organizations (the “JCAHO”). As part of its accreditation survey, the JCAHO reviews its members’ processes for identifying, reporting and responding to “sentinel events”. The purpose of these guidelines is to improve patient outcomes and avoid malpractice resulting in serious personal injury or wrongful death.

In 1996, the JCAHO promulgated “Sentinel Event Policy and Procedures”. They state in part:

I. Sentinel Events
In support of its mission to improve the quality of health care provided to the public, the Joint Commission includes the review of organizations’ activities in response to sentinel events in its accreditation process . . .

◆ A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury or loss of limb or function.
◆ Such events are called “sentinel” because they signal the need for immediate investigation and response”

II. Goals of the Policy

“The goals of the policy are four-fold:
◆ To have a positive impact in improving patient care.
◆ To focus the attention of an organization that has experienced a sentinel event on understanding the causes that underlie the event, and on making changes in the organization’s systems and processes to reduce the probability of such an event in the future.
◆ To increase the general knowledge about sentinel events, their causes, and strategies for prevention.
◆ To maintain the confidence of the public in the accreditation process”

As part of the sentinel event policy, the JCAHO requires health care organizations to perform a “root cause analysis” when a sentinel event occurs, and to use “the information from the data analysis to identify changes that will improve performance or reduce the risk of sentinel events.” To maintain JCAHO accreditation, healthcare organizations must also “ensure that the processes for identifying and managing sentinel events are defined and implemented.”

Click here for a sample Motion to Compel Production of Sentinel Event and Peer Review Documents