Department: KSMC

Policy #: APP- KSMC-006

Policy Title: SENTINEL 41 gpartment: KSMC
Policy #: APP- KSMC-006
Policy Title: SENTINEL
Ministry of Health(Hospital Administration) Mi ni stry of Hea lth
MC u a lit v
KS
King Saud Medical Complex
Quality Management
EVENT & ROOT CADS'
King Saud Medical Complex
ris ospital Administration)Quality Management
Riyadh, Kingdom of Saudi Arabia Riyadh, Kingdom of Saudi Arabia
EVENT & ROOT CAUSE

ANALYSIS

ANALYSIS
Effective Date:
Cont'd.... November 12, 2007
Revised Date:
# of Pages: 11 Fffective Date:
2. .All other hours, to the Nursing Supervisor who immediately reports
Parethe event
6of 11 to the Director on Duty.
. ovember 12, 2007
ove
vent from occurring in the future. Because the immediate cause of mostRevised Date:
sentinel events is human fallibility, the root cause analysis is expected to reveal and modify any implied system for t
# of Pages: 11
3. .If any of the above is unavailable, verbally report to the Administrator or to the Quality Management. Pa-e7of 11

.4 Requirements for Root Cause Analysis

4. .After the verbal report, a completed written report should be submitted to the Quality Management.
- 9.4.1 Focus primarily on systems and processes, not individual performance.

9.2 Appointment of Problem Solving Team

- 9.4.2 Start from identifying special causes in clinical processes until reaching the common causes in organizational pr

n of QM Committee calls a meeting with the Sentinel Event Committee to investigate the occurrence 9.4.3
and toStudy
determine whether
thoroughly by such occurrence
frequently askingmeets the definition of a sentinel event during
questions.

(48) hours. - 9.4.4 Recognize changes and progression that could have occurred in the system,
- 1

either by redesigning the existing systems or development of new systems that -would minimize the risk of such events
9.2.2-tf the Committee determines that a reasonable possibility of a sentinel event
~:-Jms occurred, the committee should appoint a PST composed of KSMC
-personnel at all levels including, but not limited to, personnel closest to the
PST must complete a "thorough" and "credible" Root Cause Analysis that include:
issue(s) involved and personnel with decision-making authority.
9.5. lAn identification of the human and other factors directly associated with the
1. The PST should investigate and understand the causes that underlie the event
sentinel event, and the processes and systems related to its occurrence.

edible root analysis and resulting action plan describing the hospital's risk reduction strategies (Appendix B) within (45) days of the known occurrence of the sentinel -event.
9.5.2Analysis of the underlying systems and processes through a series of repeated
questions designed to determine where alternatives might reduce risk.

9.3 Root Cause Analysis 9.5.3 Assignment of risk points and their potential contributions to the specific type of sentinel event.

The purpose of the root cause analysis is to understand how and why a sentinel

98 99