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Notes 6These are notes linked to from other pages on this site
4.1% They also found that medical facility employees proved the least likely source for identifying a sentinel event (less than 1% of the total cases). Or use the navigation bar below.
Sentinel Event Root cause analysis (RCA) Root cause analysis requires evidence. There is scant little of that for most adverse events because people in medicine will not report them. Medicine is a field in which even the treatments and procedures used often are backed up by little or no evidence to substantiate their effectiveness or their desirability over other options (see Mammosite, for one). In most cases there isn't even long term tracking of patients to see how various operators or procedures effect them. It is a culture that not only is not interested in evidence, but that even has habits and procedures designed to prevent collecting evidence - after all, they repeat, "you have to protect yourself from lawsuits."
According "A Newsletter from the National Patient Safety Foundation," Volume
11: Issue 4, 2008, in an article called "Root Cause Analysis: Are We Looking
for Keys Under the Lamp Post?" by Albert W. Wu, MD, MPH, Julius Cuong Pham,
MD, PHD, and Peter Pronovost, MD, PHD (all at Johns Hopkins University)
"Many people in organizations charged with carrying out RCAs are ambivalent
about them. Even if these individuals cannot articulate all of their
concerns, they intuitively believe that RCAs may not be cost-effective, or
even effective. They also have concerns about the time and effort expended,
typically ranging from 20-90 person-hours per RCA."
The full cooperation of the frontline workers is dubious, and according to the article "It is disconcerting that institutions too often seem to experience repeat occurrences of incidents shortly after an RCA is completed." Two of the things they suggest are in line with chief themes
of this web site: Health care workers will not report most of what goes wrong. It has been demonstrated that patients will report more verifiable information than health care workers when given the opportunity. Health care workers are aware of far more than patients, but will report almost none of it when it is negative. Patients are aware of far less, but will report all of it, in the end reporting a greater quantity of accurate, verifiable information than can be gotten from the health care workers. (See Annals of Internal Medicine article about Unnecessary Patient Deaths)
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Legitimate grievances resulting in suits Studdert studied only the legitimate grievances of which there was a written record. If the he had been able to include the number of legitimate grievances of which no record was made, the number of victims who were able to get lawyers would be a small fraction of one percent. How "no-fault" and blameless can a system be?
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