SENTINEL EVENT DEFINED :
SENTINEL EVENT DEFINED An unexpected occurrence involving:
Death or
Serious physical or
Psychological injury, or
Risk.
Serious injury:
loss of limb or
function.
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Such events are called "sentinel"
Signal the need for
Immediate investigation
Response
Root Cause Analysis (RCA) :
Root Cause Analysis (RCA) RCA is a technique that helps people answer the question of why? the problem occurred in the first place.
THE OBJECTIVE OF RCA :
THE OBJECTIVE OF RCA RCA is used to identify the origin of a problem.
It uses steps and tools to find the primary cause of the problem to:
Determine what happened.
Determine why it happened.
Determine what to do to reduce the likelihood that it will happen again.
KKH RCA COMPLETED AND IMPLEMENTED THE RECOMMENDATIONS :
KKH RCA COMPLETED AND IMPLEMENTED THE RECOMMENDATIONS Delay of Treatment- Histopathology Report Communication problem- 1
Blood transfusion Error- 1
Oxygen Shutdown in ICU- 1
Power Failure in ICU and AKU -2
IV Therapy Complications- 1
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