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The Joint Commissions Sentinel Event Policy implemented in 1996 is designed to help health care organizations to identify sentinel events and take action to prevent their recurrence A sentinel event is an unexpected occurrence involving death or serious physical--including loss of limb or function--or psychological injury or the risk thereof Risk thereof means that although no harm occurred this time any recurrence would carry a significant chance of a serious adverse outcome Any time a sentinel event occurs the health care organization is expected to complete a thorough and credible root cause analysis implement improvements to reduce risk and monitor the effectiveness of those improvements The root cause analysis is expected to drill down to underlying organization systems and processes that can be altered to reduce the likelihood of a failure in the future and to protect patients from harm when a failure does occur The Sentinel Event Policy also encourages organizations to report to the Joint Commission sentinel events that have resulted in death or serious injury along with their root causes and related preventive actions so that the Joint Commission can learn about the underlying causes of the sentinel events share lessons learned with other health care organizations and reduce the risk of future sentinel event occurrences For questions about the Sentinel Event Policy organizations can call the Joint Commissions Sentinel Event JCAHOorg What is Clinical Risk Management Clinical Risk Management CRM is an approach to improving the quality and safe delivery of health care by Placing special emphasis on identifying circumstances that put patients at risk of harm and Acting to prevent or control those risks The CRM program aims to identify clinical near misses incidents adverse and sentinel events through the incident reporting and the adverse event screening of medical records of patients who have died or had a an unplanned transfer to the Intensive Care Unit Bonser 2002 Such events are monitored and analyzed with the focus to examine the
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