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Sentinel Event Data Root Causes by Event Type 2004-2012

In the acyclic peer-to-peer architecture, servers communicate with each other symmetrically as peers, adopting a protocol that allows a bidirectional flow of subscriptions, advertisements, and notifications. Hence we use an undirected graph to represent the topology of this architecture. (As always, the external clients of the service use the standard client/server protocol described in Sec- tion 3.) The configuration of the connections among servers in this architecture is restricted so that the topology forms an acyclic undirected graph. Figure 6 shows an acyclic peer-to-peer architecture of servers. The communication be- tween servers is represented by thick undirected lines, while the communica- tion between clients and servers is represented by. | Sentinel Event Data Root Causes by Event Type 2004-2012 The Joint Commission Copyright The Joint Commission Joint Commission Root Cause Information www.jointcommission.orq Sentinel Event Policy and Procedures V Sentinel Events are reported to The Joint Commission voluntarily by an accredited organization www.jointcommission.orq self report form OR reported via the complaint process. www.jointcommission.orq report a complaint.aspx V When a reviewable sentinel event is reported to The Joint Commission The health care organization is required to share its root cause analysis. The root cause analysis is thoroughly reviewed by a specially trained Joint Commission clinician who then conducts a dialogue with the accredited organization to identify the root causes contributing to the event. www.jointcommission.orq Framework for Conducting a Root Cause Analysis and Action Plan V The events and their root causes are recorded in a de-identified database. y The Joint Commission Office of Quality Monitoring - 2 Copyright The Joint Commission Root Cause Definition FFundamental reason s for the failure or inefficiency of one or more processes. F Point s in the process where an intervention could reasonably be implemented to change performance and prevent an undesirable outcome. FThe majority of events have multiple root causes. Copyright The Joint Commission The Joint Commission Office of Quality Monitoring -