Human Factors – Sentinel Events: Death and Permanent Loss

The Joint Commission on Healthcare Accreditation just released its latest findings on Sentinel Events.  Here at CCG we always make sure to study the results and attempt to determine how these results can impact and improve our training curriculum to better serve our clients.

In the latest data reported, there was information provided purporting how “Human Factors” resulted in death or loss of function as they were considered a “root cause”. The JC defined “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 was reported that between 2004 and 2015 there were 160 sentinel events caused by “Human Factors”. One Hundred, Sixty. -Reported.

Take a moment to consider if you happened to be one of the family members of one of those 160 who died, or suffered permanent loss of function due to these “Human Factors”.

Human Factors and Sentinel Events: Deaths and Permanent Loss

Your child died because of low staffing levels. Your child died due to poor skill sets. Your child died due to poor staff orientation, competency, supervision, or better yet— poor in-service education. Maybe the staff attending your child were fatigued, distracted, were complacent, or simply biased, which as a result led to a situation where your child was unfairly treated, became escalated and was then restrained, which in the end, killed him/her.

Complications occur in healthcare all the time. Mistakes with the best of intentions can/will be made. That said, there is no excuse for failing to effectively train employees to prepare for crisis situations, and understand how rushing, fatigue, distraction, complacency, and bias can escalate a situation unnecessarily.

There is no excusable reason not to prepare and train staff how to identify when situations may be escalated by their own interactions, words, and behavior and related “Human Factors”.

Currently, My son is just over 5 and a half years old.  Should the day come when he may need help in some kind of psychiatric or related healthcare facility, I pray that the organization had taken the time to identify if they are doing everything they can to prevent these types of deaths from occurring.

I hope beyond hope, that the organization he may enter provides effective, modern, and realistic crisis prevention training such as this company, Crisis Consultant Group, LLC provides.

If your staff/organization can stand to benefit from more effective crisis prevention and intervention training, contact us today. Let’s make sure that 160 number gets to zero as soon as we possibly can.