The spokesperson for Princess Margaret Hospital (PMH) today (September 8) released the findings and recommendations of a root cause analysis investigation on a sentinel event
, which was announced earlier by the hospital.
We often hear of whanau waiting outside the mortuary, separated from their loved one by walls and a bureaucratic technical process that categorises your loved one as a coroner's case, a Health and Disability Commissioner HDC case, a sentinel event
, or a death in police custody," Pakeho said.
On March 1, 2017, The Joint Commission issued a sentinel event
alert on the essential role of leadership in developing a safety culture (The Joint Commission, 2017a).
Patient Safety Systems Chapter, Sentinel Event
Policy and RCA2 [cited 2016 Jan].
Safety and quality of patient care are dependent on teamwork, communication and a collaborative work environment, leading the commission to publish Sentinel Event
40, which mandates that commission-approved facilities establish policies and procedures to address behavioral issues.
7) Similarly in a 2013 Sentinel Event
Alert, the Joint Commission specifically includes vaginal sponge retention as a reportable sentinel event
that is a violation of patient safety and quality of care.
The Joint Commission (formerly the JCAHO-Joint Commission on Accreditation of Healthcare Organizations) recognizing the urgency of the suicide problem, issued a Sentinel Event
Alert on February 24, 2016.
The Joint Commission (2011) issued a Sentinel Event
Alert on healthcare worker fatigue and patient safety, listing the following impacts of fatigue:
The sentinel event
of my life, apart from my decision to follow Christ, was the day I stopped my car at Duke University's East Campus to give several girls a ride to Wright Refuge, an emergency foster care facility, where we would spend the afternoon playing and tutoring the children.
The Joint Commission released its 40th Sentinel Event
Alert way back on July 9, 2008.
As discussed in the National Institute of Justice (NIJ) Special Report Mending Justice: Sentinel Event
Reviews, published in September 2014, some believe the criminal justice system lacks a feature that medicine, aviation and other high-risk enterprises see as critical: a way to account for tragic outcomes and using those lessons to reduce risk of recurrence.
In June 2008, the Joint Commission issued a Sentinel Event
Alert describing "behaviors that undermine a culture of safety.