“The contribution that human resources management makes to a hospital’s ability to provide safe, quality care cannot be overestimated. The quality of the hospital’s staff will, in large part, determine the quality of the care, treatment, and services it provides.”The Joint Commission

While The Joint Commission (TJC) cautions not to draw conclusions from the low number of sentinel events reported each year, the consistency of the root cause of the events, no matter how small, cannot be ignored. Though most sentinel events are the result of several root causes, TJC recently announced human factors as the most frequently identified root cause of sentinel events for the fourth year in a row.

What are sentinel events?

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Such events are called “sentinel” because they signal the need for immediate investigation and response. Not all sentinel events occur because of an error, and not all errors result in sentinel events. When an event is reported to TJC, the healthcare organization is required to share its root cause analysis which is subsequently reviewed by TJC. The idea behind reporting sentinel events is based on the same concept that gave birth to TJC—sharing best practices. The sentinel event reporting process details errors and what caused them to occur—thus sharing ways to prevent them from happening again. However, the low number of events reported show that many facilities are reluctant to report errors, even though a facility’s accreditation status is not affected, and all reported events are legally protected in the courts by TJC.

What are “human factors?”

TJC defines human factors as “staffing levels, staffing skill mix, staff orientation, in-service education, competency assessment, staff supervision, resident supervision, medical staff credentialing/privileging, medical staff peer review, other (e.g., rushing, fatigue, distraction, complacency, bias).” It’s ensuring the person performing the action not only has the right skill level, but has also gone through an adequate facility orientation. It’s making sure the clinician uses the equipment properly, and that equipment has been serviced by a qualified individual. It’s the monitoring of competency—ensuring all who touch patients are up-to-date on certifications and recurrent training. It’s even making sure a facility has reached a herd factor of immunity for seasonal flu, measles, and pertussis.

How do “human factors” affect patient safety?

No matter how you look at it, human factors affect patient safety. They are a major reason for unexpected occurrences that have the potential to harm a patient. Good administrators know that when their staff is comprised of competent, well-trained individuals working together following standards and policies, negative outcomes can be minimized. The World Health Report 2000—Health Systems: Improving Performance report states “the performance of health care systems depends ultimately on the knowledge, skills, and motivation of the people responsible for delivering services.” The WHO report goes on to explain that knowledge may not deteriorate with use but, like equipment, old skills become obsolete with the development of new technologies. Continuous training and the management of that training requires non-stop effort and is essential to keeping patients safe.

What can be done to reduce sentinel events?

With IntelliCentrics , you have the online tools to effectively manage human factors. You will be able to determine, using our up-to-date compilation of best practices and regulatory requirements, the credentials you should require for each role in your healthcare community. Your entire staff can be credentialed through, making it easy to know everyone’s current skills and competencies. You will also be able to track the ongoing education and training requirements of each person. Our cloud-based solution automatically checks for errors and advises stakeholders of any issue. It also sends automated reminders of requirements to each user to drive compliancy. Though human error can never be completely eliminated, with , you will be able to ensure that errors are the exception and not the rule.


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