The history of risk management in health care organizations dates back to the Babylonian Code of Hammurabi. This code stipulated severe punishment for medical practitioners who through malpractice caused injuries or even death to patients. The escalated law suites occasioned by malpractices made health care providers face an unprecedented crisis in the 1970s. Due to the high rise of litigations involving huge sums of money, healthcare providers, therefore, decided to put in place risk management personnel together with activities and programs. The above-mentioned were earmarked to cub adverse patient outcomes and potentially compensable events (Stanhope, 2006). This essay, therefore, seeks to define risk management in health care delivery, discuss the basics of sentinel reporting, the legal implications of sentinel events, and finally, discuss how healthcare administrators can develop an effective risk management program.
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Risk management in healthcare delivery defined
Risk management in its simplest form refers to an organizational function geared towards preventing accidents and injuries and mitigating financial loss. In healthcare delivery, the main focus of risk management is to lower harm that can be avoided by; patients, visitors, and staff. In order to achieve this, a structured program aimed at identifying problems and resolving them must be put in place, staff sensitization and education should be carried out, and there should be enhanced patient relations.
According to Tingle and Cribb (2002), Risk management incorporates all the different elements found in clinical governance. Furthermore, it brings together the frameworks needed for accountability and clear reporting mechanisms mandatory in meeting the corporate governance and control assurance requirements. Proper and successful risk management awareness and practice at all levels are very important to any organization. It is worth noting that, the risk is eminent in everything an organization does for instance; in treating patients, purchase of new medical equipment, patients’ adverse reactions to drugs, and many others. Through risk management patients are able to receive the best service by getting a balance in risk management, quality, and law. In addition, risk management allows for the establishment of disciplinary standards of care and good practice guidelines that promote high professionalism in nursing and medicine.
The basics of sentinel event reporting
The joint commission, in a bid to better the quality of healthcare provided to the public, puts into consideration the review of the organization’s activities in its accreditation process. The process encompasses both full accreditation surveys and random surveys. The joint commission (2009) defines a sentinel event as “one involving death or serious physical or psychological injury or the risk thereof”. A sentinel event is “one that calls for immediate investigation and response”. Furthermore, these events are not very frequent and are independent of the patients’ conditions. In essence, what these events reflect are; hospital systems and process deficiencies and often bring about unnecessary outcomes for patients. When a sentinel event happens in a healthcare setting, healthcare administrators are required to report its occurrence to the department of health. Reportable sentinel events may include but are not limited to the following: wrong procedures resulting in death or major permanent loss of function, hemolytic blood transfusion accessioned by ABO incompatibility, suicide cases in an inpatient unit, infant discharge to a wrong family, a patient’s death resulting from wrong drug administration and other events considered to be catastrophic. However, the frequency of the occurrence of sentinel events can be minimized by assessing the settings in which they occur, and putting in place the changes required, which may reduce the occurrence of a similar event in the future. Sentinel event reporting, is very important to a healthcare organization as it focuses more on the healthcare provider as a whole rather than a blame castor to the individuals. This then leads to a reduced rate of errors at all levels and promotes accountability among the staff members.
Root cause analysis; procedures and timelines
In a nutshell, Root Cause Analysis (RCA) is a method used in process analysis. It is vital in the identification of causal factors of catastrophic events. RCA is a very important tool in any safety management system since it seeks to answer questions posed by high risk and high impact events. For instance, it gives answers as to what happened, reasons for occurrence, and measures to prevent the occurrence in the future. Therefore, RCA provides an avenue for investigation and solution generation by risk managers in their endeavor to identify causes and to provide solutions to address system failure. RCA analysis can be undertaken on sentinel events because they bear high-risk high-impact events (Joint commission 2009).
RCA process should be conducted as soon as practical after the sentinel event occurs. This is aimed at ensuring that the information Gathered is reliable because when more time passes by, there may be a lapse in the recollection of events from those involved. Due to the time factor involved, an RCA team should be convened within two working days of the event occurrence. In addition, an RCA report should be ready within two months from the day investigations commenced. Healthcare organizations have an obligation of ensuring that, they notify the joint commission of a sentinel event by filling out a sentinel event notification form and submitting report findings together with a risk reduction action plan (Joint commission 2009).
The legal implications of sentinel events
However significant sentinel event reporting is, it is impossible for medical practitioners to guarantee outcomes to their patients, there is always a potential risk involved in every medical encounter. Because of this, there is always bound to be a medical malpractice claim accessioned by real or perceived negligence. Patients or their representatives can therefore file a malpractice suit demanding compensation for an injury allegedly caused by negligence. In some instances patients succeed when they demonstrate and prove in a court of law that, the medical professional had a duty to provide care, he breached that duty, that the breach of duty caused injury and that, damages were involved. Throughout the United States, there is existing law pertaining to confidentiality, protection, and admissibility in the litigation of patient care. These laws were specifically put in place to encourage evaluations and to enable medical professionals to carry out their duties without fear. Due to sentinel event reporting to the joint commission, there is a lack of confidentiality and potential discoverability. Furthermore, individual professionals could use root cause analysis to defend themselves against indiscipline or use it to blame the healthcare organization (Joint Commission on Accreditation of Health Organizations 2005).
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A combination of the Principles of TQM/CQI with sentinel analysis and root cause management in developing an effective risk management program.
Healthcare delivery is a very sensitive undertaking that calls for absolute caution since it involves lives. Healthcare providers, therefore, have a duty to provide patients with this important service at minimal risks. In healthcare, Total Quality Management is used interchangeably with Continuous Quality Improvement. TQM operates on the principle of “purpose constancy” and a well-mapped procedure to measure process steps through outcomes. CQI on the other hand is usually used in healthcare and is based on the principle that there is room for continuous processes improvement. Both the above mentioned can be incorporated by healthcare providers together with sentinel event analysis and RCA analysis in order for them to come up with a more elaborate and effective risk management program. This can be achieved because all the above is geared towards better outcomes and a reduction in errors.
Risk management is a deliberate attempt to identify the root cause of errors in a process and find solutions to minimize the harm caused to patients. The joint commission demands that healthcare organizations carry out sentinel event analysis and provide a report of their findings within a timeline of two months and put into place measures to reduce the reoccurrence of such events in the near future. Health care organizations can combine TQM, CQI, sentinel event reporting, and RCA when coming up with elaborate and effective risk management programs.
Joint Commission on Accreditation of Health Organizations (2005). What every Health Care Organization should Know about Sentinel Events. New York: Joint Commission Resources.
Stanhope, L. (2006). Nursing in the Community. Sydney: Elsevier Health Sciences.
The Joint Commission (2009). Sentinel Event. Web.
Tingle, J., & Cribb, A. (2002). Nursing Law and Ethics. Oxford: Blackwell Publishing.