Root cause analys is and improving strategy of suicidal sentinel events

Lim, Hun-Sun; Kim, Hong-Soon; Yum, Ho-Kee

Quality Improvement in Health Care 2013;19(2): 50.
Published online December 30, 2013.

의료기관 내 자살사건의 근본원인분석과 개선전략

임헌선¹, 김홍순², 염호기³

¹가천대 길병원 적정진료관리본부
²가천대 길병원 마취통증의학과
³인제대학교 서울백병원 호흡기내과

Root cause analys is and improving strategy of suicidal sentinel events

Hun-Sun Lim¹, Hong-Soon Kim², Ho-Kee Yum³

¹Department of Quality Improvement, Cachon Uninversity, Gil Medical Center
²Department of Anesthesiology, Cachon Uninversity, Gil Medical Center
³Department of Pulmonary and Critical Care Medicine, Inje University, Seoul Paik Hospital

Abstract

Objectives
Suicide is a serious sentinel event in healthcare organization. Suicide and suicidal attempt are fatal and long lasting mental and physical damage to themselves, family, and medical staffs. To develope the system to prevent suicidal accident in hospital, we reviewed and analysed one case of suicidal sentinel event.
Methods
The risks of suicidal sentinel event were evaluated and analysed through the root cause analysis and failure mode effects analysis.
Result
We found several root causes such as initial assessment of oldest patient and security issues. Couple of action plans to fix the problems were done immediately. According to failure mode, we evaluate the risk priority number to modify the action plans.
Conclusion
To reduce the risk of sentinel events, we reviewed the suicidal event and established the new system and action plan to prevent sentinel events.

Key words suicide;sentinel event;RCA;FMEA;