Empathetic and Effective Response to Sentinel Events and Root Cause Analysis

by Tammy Williams, RN, MSN, CPPS
Vizient PI Program Director

In a culture of safety, accountability and learning, healthcare leaders make patient and workforce safety an organizational priority, design safe systems, and build a culture and systems to support resilience after a sentinel event (a patient safety event that results in death, permanent harm or severe temporary harm). Because health care is provided in highly complex environments and systems, it is the ultimate responsibility of healthcare leaders to know and address the risks in their organizations that can lead to these types of events.

Vizient’s Patient Safety Organization (PSO) recently convened experts across the nation to identify leading practices to support an empathetic, effective and sustainable hospital response after a sentinel event. They identified several opportunities to achieve an empathetic and effective response to a sentinel event, including:

Open, honest and compassionate communication with the patient and family

• Communication with patients and families after an adverse event was inconsistent and standard education on how to communicate with patients after an adverse event was not provided to all members of the team.
• With the recent introduction of the Cures Act Final Rule requiring organizations provide patients with timely, virtual access to their medical record, hospitalized patients were accessing their medical information before their doctor. To maintain the same level of transparency and trust, providers may need to modify the way they work to ensure their communication is timely when an error occurs—whether the patient was harmed or not.

Support for the clinicians involved in the event

• Team members involved in the event were excluded from the Root Cause Analysis (RCA) meetings even though involvement promotes learning, healing and resilience.
• Staff viewed the response to adverse events as punitive, rather than supportive.

A thorough, credible and non-punitive RCA process

• Organizations may not have established criteria for when to obtain an external expert to achieve a thorough, objective and credible review.
• The aim of the analysis was to get to a single main or root cause rather than multiple systemic causal factors in the sequence of events so multiple fixes and barriers could be identified to mitigate risk.
• Team members involved in the event were excluded from the RCA meetings despite their unique knowledge about what happened and how systems issues may have influenced individual decision-making given the context and conditions present at the time of the events.
• Failure to consistently use a standard format for triggering questions during event review may contribute to incomplete inquiries and inadequate identification of system factors and make the process feel more punitive to frontline staff.

Effectiveness of RCA process

• Leaders were concerned about the time and resources invested in the RCA process when the same or similar events recurred.
• Action plans were not comprehensive or there was no formal way to measure the effectiveness of actions.
• Organizations did not have a safety surveillance dashboard, or dashboards were fragmented and lacked centralized oversight. A consistent process to review, reprioritize risks and improve the dashboard was lacking.   

Building on existing recommendations to incorporate current thought leadership to support an empathetic, effective response after a sentinel event, the experts made several recommendations, including:

Develop a continuous safety surveillance system

• A robust safety surveillance system includes process and outcome measures based on prioritized risks to warn the organization of impending risks before patients are harmed.

Develop the foundation to promote healing, learning and system improvement

• Standard education is provided to the health care team on how to communicate with a patient and their family after a serious adverse event based on their role and responsibilities.
• Real-time honest, open, and compassionate communication and support for the patient and family involved in an adverse event align with the 21st Century Cures Act.
• Clinicians are provided compassionate support by their peers in an environment that allows them to tell their stories to promote healing.

Conduct a thorough, objective and credible RCA

• Criteria are established for when external support is required for an objective RCA.
• The healthcare team involved in the event is included in RCA meetings, solution selection and action planning.
• A standard format for triggering questions and a taxonomy of causal factors and descriptions addresses issues related to health equity, health information technology and access to care. Triggering questions are used consistently to ensure the review is comprehensive and does not seem punitive to staff.

Develop management systems

• To ensure that actions are carried out as intended, management systems, manager development and standard processes must be in place to support action owners, managers and frontline staff in implementing the plan successfully. The action plan is integrated into standard work.
• Managers educate their staff on the new standard work, monitor compliance in real-time through daily observations, provide in-the-moment coaching and document compliance on a visual management board.
• A process for oversight of the action plan occurs by leaders at the organization and system levels. Barriers to the provision of safe care and the action plan are identified and removed. The measures of success from the RCA action plan are integrated into the surveillance dashboard.

These leading practices offered by industry experts support an effective and empathetic response to sentinel events and actions that sustain improvements. Leading practices, along with additional insights, were assembled into a whitepaper available to Vizient members.

For additional resources related to accelerating improvements in patient safety outcomes and quality of care, visit vizientinc.com.