Quick Review Cards for Medical Laboratory Science

Sentinel Events: The Joint Commission (TJC)

Management &

Education Review 587

Definition

Example

Goals

Requirements

Reporting

Unexpected event involving death or serious physical or psychological injury, or risk thereof

Administration of ABO-incompatible blood

Improved patient care

1. Root cause analysis: Analysis of why event happened. Examines proximate causes, e.g., personnel, equipment,
   environment, leadership, corporate culture, communication, external factors. Focuses on systems/processes,
   not individuals.


2. Action plan: Establishes risk reduction strategies & measures of effectiveness. Should delineate responsibilities
   for implementation/oversight & establish time lines.


3. Implementation.


4. Monitoring.

Reporting to TJC is optional but encouraged so that event can be added to database & used as educational tool to

help others avoid similar events. Confidentiality is maintained.