Nursing

Sentinel events in the delivery room blamed on communication breakdown and staff incompetence

Staff Development Weekly: Insight on Evidence-Based Practice in Education, December 3, 2004

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In August, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released a Sentinel Event Alert highlighting communication breakdown among staff in neonatal areas as a possible cause of infant death and permanent injury during delivery, according to the JCAHO. Out of the 47 cases reported in the original alert-which has now jumped to 71 cases-over half of the organizations involved reported problems with communication such as organizational culture (i.e., hierarchy and intimidation), as the main barriers to effective communication and teamwork, according to the alert. Other root causes for mistakes in neonatal areas include staff competency (47%) and orientation and training process (40%). The following are some of the measures taken by the organizations involved in the sentinel events to avoid future events:

 Standardize the evaluation and monitoring process
 Revise the conflict resolution policy
 Reinforce chain-of-communication policy
 Revise orientation and training process
 Revise competency assessment

Click here < http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_30.htm> to view the JCAHO's sentinel event alert.

HCPro is in no way affiliated with the Joint Commission on Accreditation of Healthcare Organizations, which owns the JCAHO trademark.



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