The primary purpose of a sentinel event review, particularly in the context of never events, is to identify and implement sustainable systems-based improvements. Here’s why:
Focus on Systemic Issues:
Sentinel event reviews aim to uncover underlying system flaws that contributed to the event. By focusing on systems-based improvements, the organization can preventrecurrence and enhance overall safety.
Long-term Impact:
Sustainable improvements ensure that changes made as a result of the review have a lasting impact on patient safety, rather than just addressing the immediate issue.
Holistic Approach:
Addressing system-wide issues, rather than just individual performance gaps, promotes a culture of safety and continuous improvement across the organization.
Compliance and Accreditation:
Regulatory bodies and accreditation organizations emphasize the importance of systems-based improvements following sentinel event reviews, aligning with best practices in patient safety.
While engaging leadership, identifying performance gaps, and monitoring involvement are important aspects of a sentinel event review, the ultimate goal is to implement changes that improve the safety of the system as a whole.
[References:, NAHQ Guide to Sentinel Event Management and Never Event Prevention, NAHQ Healthcare Quality Competency Framework: Patient Safety and Risk Management, , =========, , , , ]
