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#9. What do you make of the relative preponderance of suicides among the recently released data about reported sentinel events (Of 562 sentinel events reviewed by JCAHO from 1/95 through 7/99, 117 were patient suicides)?

There were, I suspect, many more than 562 sentinel events which occurred during this period (and JCAHO does not suggest otherwise). Indeed, the Harvard Medical Practice Study suggests that approximately 1,300,000 disabilities and 180,000 deaths occur as a result of (iatrogenic) sentinel events annually. Given the discrepancy between an estimated nearly six million sentinel events occurring and 562 being reported, one must be rather cautious about draing conclusion based upon such a small sample. Were these distrobutions to hold true for larger sample size however, one must consider the following. Of the various major categories of sentinel events, patient suicide is one of the most difficult to keep out of public and JCAHO awareness. I therefore feel that it is likely that the number of patient suicides reported (117) is closer to an accurate accounting than is true of statistics for most of the other sentinel event categories, though all sentinel events are drastically under-reported. But we must await more data to be "certain."

 

  

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About MRMA.  Automate Root Cause Analysis.  Root Cause Analysis Training Comments.  Copyright.  Costeffective Root Cause Analysis.  Credible Root Cause Analysis.  Protection from Discoverability.  Reporting of Sentinel Events to JCAHO.  Root Cause Analysis Cost.  JCAHO Requirement for Root Cause Analysis  JCAHO Sentinel Event Reporting Options.  Proximate cause, root cause versus contributory factor.  Root Cause Analysis on Non-Sentinel Events.  RCA on Sentinel versus Adverse Event.  Reaction to JCAHO Sentinel Event Policy.  Suicide RCA Data.  Root Cause Analysis Policy Implementation.  Root Cause Analysis Standards.  Software facilitation of root cause analysis.  Thorough & Credible Root Cause Analysis.  DoD Sentinel Event Reporting.  Literature Review in Root Cause Analysis.  Root Cause Analysis Training.  FAQ's on Root Cause Analysis.  FOCUS-PDCA.  Guestbook.  Implementing Root Cause Analysis Policy.  MRMA Home.  Inforequest.  Links.  Patient-Doctor Dialog.  Freedom from Restraint.  JCAHO Reporting Options.  Root Cause Analyst.  Thankyou.  Root Cause Analysis Theory.  Root Cause Analysis Training.  Root Cause Analysis Training.  Sample Root Cause Analysis Report.  Sample RCA Contributory Factor Tree Diagram.  Root Cause Analysis Reporting Form. 
About MRMA.  Automate Root Cause Analysis.  Root Cause Analysis Training Comments.  Copyright.  Costeffective Root Cause Analysis.  Credible Root Cause Analysis.  Protection from Discoverability.  Reporting of Sentinel Events to JCAHO.  Root Cause Analysis Cost.  JCAHO Requirement for Root Cause Analysis.  JCAHO Sentinel Event Reporting Options.  Proximate cause, root cause versus contributory factor.  Root Cause Analysis on Non-Sentinel Events.  RCA on Sentinel versus Adverse Event.  Reaction to JCAHO Sentinel Event Policy.  Suicide RCA Data.  Root Cause Analysis Policy Implementation.  Root Cause Analysis Standards.  Software facilitation of root cause analysis.  Thorough & Credible Root Cause Analysis.  DoD Sentinel Event Reporting.  Literature Review in Root Cause Analysis.  Root Cause Analysis Training.  FAQ's on Root Cause Analysis.  FOCUS-PDCA.  Guestbook.  Implementing Root Cause Analysis Policy.  MRMA Home.  Inforequest.  Links.  Patient-Doctor Dialog.  Freedom from Restraint.  JCAHO Reporting Options.  Root Cause Analyst.  Thankyou.  Root Cause Analysis Theory.  Root Cause Analysis Training.  Medical Risk Management Associates.  Sample Root Cause Analysis Report.  Sample RCA Contributory Factor Tree Diagram.  Root Cause Analysis Reporting Form.