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 prevent recurrence 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
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