99). The JCAHO emphasizes that, "In support of its mission to improve the quality of health care provided to the public, the Joint Commission includes the review of organizations' activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys" (Sentinel event, 2008, p. 2). The JCAHO also points out that many healthcare providers may be reluctant to report sentinel events for fear of being labeled a "whistleblower" or the potential for retribution by management (Sentinel event, 2008). Notwithstanding this pragmatic rationale, a more important reason to report adverse events in a healthcare setting is the fact that they represent opportunities for improvement and these issues are discussed further below. 3. Discuss how healthcare administrators can combine the principles of TQM/CQI with Sentinel Event Reporting and Root Cause Analysis in developing an effective risk management program.

In reality, there is nothing particularly mysterious or difficult about sentinel event reporting and root cause analyses and the techniques are fairly straightforward. By keeping track of a healthcare facility's sentinel events and graphing this data, it is possible to identify significant problem areas in a timely fashion. The same techniques that are already being used by healthcare facilities for total quality management and continuous quality improvement initiatives can be readily applied to the analysis of sentinel events. By quantifying the number of such adverse events and trending this information, problem categories can be identified and...

For example, during the 4-year period from 1995 through 1998, just 374 sentinel events were reported to and reviewed by the JCAHO; however, this relatively meager sample of the much larger constellation of medical misadventures clearly indicated that just three of the twenty-two problem categories represented almost half (45%) of the events reported (i..e., patient suicide (80 cases), medication error (59 cases), and operative or postoperative complication (29 cases) (Sherman). According to this author, "Sentinel event reporting can be an extremely powerful tool as the industry moves forward" (p. 99). This tool, though, is only as powerful to the extent that healthcare facilities actually report such sentinel events so that remedial steps can be taken to resolve them.
References

Gilley, J.W. & Maycunich, a. (2000). Organizational learning, performance, and change: An introduction to strategic human resource development. Cambridge, MA: Perseus Books.

Berntsen, K.J. (2004). The patient's guide to preventing medical errors. Westport, CT: Praeger.

Sentinel event. (2008). Joint Commission on Accreditation of Healthcare Organizations. [Online]. Available: http://www.jointcommission.org/SentinelEvents/.

Sentinel event alert. (2008). Joint Commission on Accreditation of Healthcare Organizations. [Online]. Available: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/.

Sherman, V.C. (1999). Raising standards in American health care: Best people, best practices, best results. San Francisco: Jossey-Bass.