By Dr. Anthony Policastro

The Joint Commission on Accreditation of Hospitals (JCAHO) has many procedures that hospitals should follow. One of those is what is known as their Sentinel Event policy. They even have a specific definition for it.

“A sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm.” They have an approach to dealing with events such as these. It is called a root cause analysis.

A root cause analysis has multiple steps. The first is to ask a group of questions about what went wrong. Most of those questions focus on the process involved. Most medical processes have multiple steps.

Questions involve what was supposed to happen. They involve what did not happen the way it was supposed to. They involve whether there was a human error. They involve whether there was an equipment error. They ask if the staff was properly trained to perform the process. They ask about team communication errors.

These questions provide a framework for finding what actually failed in the steps of the process. The failure might include communication errors. The failure might include equipment malfunction. The failure might involve human error. The failure might involve inadequate oversight.

Once these things are identified actions are put into place. They might involve replacing defective equipment. They might involve putting steps in that will decrease the margin for human error. 

An example of this was the one I used several months ago. We had bottles of potassium hydroxide and saline in the ER. It resulted in nurses mistakenly putting potassium hydroxide in patients eyes thinking it was saline. We went to single use vials of potassium hydroxide and changed the process.

Before the JCAHO began this process, we had a similar one in the Air Force medical arena. It was called a critical incident investigation. If something went seriously wrong with a patient at one base an investigator from another base was sent to look at it.

I was chosen to look at the pediatric critical incident investigations by headquarters. Most of them involved newborns. I noticed that the six cases I was given involved pediatricians that had completed their training prior to 1972. That was when I started my internship. Neonatal care was in its infancy. 

So we looked at how many pediatricians among the 17 bases in the command had trained before neonatology existed. There were 11 of them. Six had already been identified. The other five worked at small Air Force bases where they did no deliveries. The result was to assign all 11 of them to small bases like that. The problem was that we had assigned them to do something they had never learned in the first place.

We see similar things outside the medical field. For example, as an Air Force Hospital Commander, I had a top secret clearance. Couriers would deliver classified, secret or top secret documents to my office. They remained in the office while I read the document and signed off on it. They would then take the document with them. The process worked well to secure the documents.

COVID update- Nationally the total number of cases dropped from 491,000 to 279,000 last week. Sussex County remains in a high risk area for COVID-19. However all the numbers have begun to improve. The total number of new cases this week was at 327 after being at 456 two weeks ago. Admissions and percent of patients hospitalized with COVID-19 infection have also dropped locally.

The most recent surge began on Nov. 28. You might remember that surges run through the population in about 75 days. We will hit 75 days on about Feb. 11. Therefore, the pattern is looking similar to past surges.