Immediate and long-term action steps to reduce risk including rationale for non-action.

Changes that could be made in systems and processes (either through redesign or development of new systems or processes) that would reduce the risk of such events occurring the futureīased on the RCA, using our proprietary SET framework, develop a customized action plan addressing:.

Identification of risk points within operational/clinical practices and their potential contributions to the type of event.

Systems and processes – not individual performance.

The overall objectives of the Provident RCA methodology are to focus on: All data can be segregated as needed and kept confidential. In addition, SET can be tailored to include your organization’s peer review process providing you with the ability to conduct peer review and sentinel events investigation simultaneously.

Expert Review: expert review regarding the standard of care rendered, documentation of care rendered in the record and causation.

Clinical Record Review: review of medical record (paper and/or electronic) for standard of care and documentation of care provided.

Interviews: interviews with all healthcare providers potentially involved in the occurrence including supervisory personnel.

Document Review: any incident reports, written policies and procedures, any logs of providers on the floor/potentially involved in care.

SET provides a framework for conducting and confidentially storing the following: Using our SET investigation templates and checklists, conduct a non-biased review using a consistent approach customized to the potential sentinel event.

Recommendations for sentinel event “reporting tree” including but not limited to both the General Counsel and Corporate Compliance departments.

Creation of a formal reporting process/dashboard within SET to keep key stakeholders apprised of sentinel events.

Development of auditing and monitoring process within SET to identify key risk areas such as wrong patient, wrong, site, and wrong procedures or unintended retention foreign body.

Use of SET to capture key quality metrics.

Development of general policies and procedures that include clear guidance and sentinel event examples.

Provident’s sentinel events approach allows an organization to detect, investigate, report and remediate potential sentinel events and their root causes.

Accumulate data for potential external reporting and training and education.Develop and track the progress of any action plan created.Provide expert witness/es secure access to key information necessary for the expert review.Confidentially conduct any required peer review activities.Conduct internally consistent interviews.Confidentially store sentinel event related documentation.Report to key organization stakeholders through the web-based dashboard.Centrally collect key data metrics for identification of risk areas.Provident’s Sentinel Event web-based Tool (“SET”), hosted by Provident, allows an organization to: Our comprehensive approach helps an organization to detect, investigate, and remediate potential sentinel events and their root causes resulting in systemic, continuous improvement in quality and compliance. Our focus is to provide an organization with systemic tools to proactively detect and remediate sentinel events – not ad hoc, reactive options. Our goal is to help prevent these types of adverse events from occurring again.The Provident Sentinel Events methodology provides for consistent, thorough, and credible detection and remediation of sentinel events. “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. “Covid-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” Kaafarani said in a statement accompanying the report.

Health facilities stripped of Joint Commission accreditation could find their Medicare funding in jeopardy. The Joint Commission accredits and certifies more than 22,000 hospitals, health systems, facilities and programs in the U.S. Nearly 90% of sentinel events occurred in a hospital, the Joint Commission said. The Joint Commission, which reviewed more than 1,400 sentinel events last year, blamed “failures in communication” and healthcare providers not “consistently following policies” as the leading causes of sentinel events.

A sentinel event