Adverse Incident Reporting and Tracking

  A workplace incident is categorized by severity, and generally defined as a situation or occurrence that adversely affects the safety and well-being of the people and/or operation of a facility. In order to deal with a workplace incident adequately, management must establish a plan for investigating, reporting and correcting the things that contributed to[…]

Peer Review Statutes: Protection From Discoverability

Reprinted with permission from: The Joint Commission Advisor for Behavioral Health Care Providers, June 1999, 3(6), pp 1-4. While this article focuses on behavioral health, the comments are fully applicable to health care in general.   It’s a thorny issue, and one that lawmakers are not likely to resolve anytime soon: How can behavioral health care[…]

Root Cause Analysis and Sentinel Event Policy Implementation: Lessons Learned

First Considerations Assessment of your organization’s “reality” Ask the hard questions Discover feasibility “up-front” Write or revise your plan of action Add or revise policies and procedures (include flow charts) Responsibility and accountability – who does what? Training Methods for monitoring & feedback Implement, monitor and make necessary adjustments Assess: Top Leadership Acceptance of the[…]

Peer Review and Morbidity/Mortality Reviews in Healthcare

Software Facilitation   CCD Health Systems owns and promotes its methodology for conducting cost-effective root cause analysis in the healthcare environment. This methodology also provides an effective and standardized process for performing peer reviews and morbidity/mortality reviews.   Root Cause Analyst® is the software product based upon that methodology. It is designed to lead an[…]

Options for Reporting of Healthcare Sentinel Events to The Joint Commission

PEER REVIEW STATUTES: PROTECTING YOUR INTERESTS Reprinted with permission from: The Joint Commission Advisor for Behavioral Health Care Providers, June 1999, 3(6), pp 1-4. While this article focuses on behavioral health, the comments are fully applicable to health care in general.   . . if the organization has concerns about increased risk of legal exposure as[…]

Common Errors in Healthcare Failure Mode and Effects Analysis (HFMEA®)

With the burgeoning interest in healthcare failure mode and effects analysis (HFMEA®), there have unfortunately been systematic errors injected into the methodology, even in the examples promulgated by the leaders in the patient safety movement. The errors are in design and application of the HFMEA methodology, as it was transitioned from its non-healthcare origins to[…]

Conducting a Cost-Effective Root Cause Analysis

Prelude: If you have a sentinel event, and if you don’t have a formal process already in place, you’ve essentially lost this battle already, because you’re in the position of crisis functioning. Recoup by bearing in mind that the JCAHO is expecting a gradual development of processes for conducting Root Cause Analyses™, and is likely[…]

RCA Best Practices – Healthcare Administration

Using multi-disciplinary teams to conduct Root Cause Analysis leads to innovative solutions while simultaneously transforming group dynamics By: Denise G. Osborn, JD, MPH(2008)   What is Root Cause Analysis? Root Cause Analysis (RCA) is an effective tool that can be used to study why something that is undesirable has happened. A multi-disciplinary team works collaboratively[…]

Theory, Philosophy and Justification for Root Cause Analysis

The move to conduct root cause analysis is largely motivated by a growing recognition that the complexity of health care and health care delivery drives the incidence of adverse events uncomfortably and unacceptably high (Brennan et al, 1991). Consistent with this, the National Patient Safety Foundation (NPSF) maintains as its philosophy that:   Most errors[…]