TAILIEUCHUNG - Kaiser Permanente’s Response to JCAHO’s Sentinel Event Standards: Our Significant Event Root-Cause Analysis Program Leads to Preventing Medical Errors

First we must determine what is important. Do we need all log data from every critical system in order to perform security, response, and audit? Will we need all that data at lightning speed? (Most likely, we will not.) How much data can the network and collection tool actually handle under load? What is the threshold before networks bottleneck and/or the SIEM is rendered unusable, not unlike a denial of service (DOS)? These are variables that every organization must consider as they hold SIEM to standards that best suit their operational goals | By Ricki Stajer RN MA CPHQ Bud Pate BA REhS Kaiser Permanente s Response to JCAHO s Sentinel Event Standards Our Significant Event Root-Cause Analysis Program Leads to Preventing Medical Errors This article explains Kaiser Permanente s Programwide policy regarding Significant Events and how this policy meets JCAHO standards regarding Sentinel Events. The Root-Cause Analysis Program developed in the California Division-Southern California Region to support this policy is described in detail with particular emphasis illustrating our focus on patient safety and risk reduction in our health care delivery systems. Since the policy went into effect in April 1998 our work has led us to conclude that blaming individuals solely when an adverse event occurs hinders our ability to find the true root cause whose correction will prevent the adverse event from recurring. Similar findings are noted in relevant literature. Introduction The prevalence of medical errors has galvanized health care leaders regulators politicians and accreditors around the issue of improving patient safety. Proposals for mandatory reporting of medical errors are currently being studied by the US Congress at the same time the Joint Commission for the Accreditation of Health Care Organizations JCAHO has heightened its requirements for analyzing root causes of Sentinel Events. Health care is an inherently risky business that is also extremely complex and becoming increasingly so. Hospital care is more complicated patients are sicker choices among medications are more numerous and technology is more sophisticated than ever before. Paradoxically the technologic advances that help achieve medical miracles also increase the chances that something will go wrong. Although some medical errors are inevitable many are preventable. Most medical errors are not the result of negligence or incompetence but of faulty systems and poorly designed processes that increase the likelihood of mistakes. We believe that frank .

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