August 24, 2009 | Barb Carr

“1,200 veterans wrongly told they got fatal disease”… is this a Sentinel Event?

“Denise Nichols, the vice president of the National Gulf War Resource Center, says the VA is blaming a coding error for the mistake.”

Where would this event be placed for investigation… the Quality Group? …… the Risk Group? Would it get a thorough Root Cause Analysis? Where would you start… with the Coding problem? … when the notifications were sent out? When the problem was caught?

The answer is all of the above! Problem is that often quality issues will not get the level of attention as would a Sentinel Event. Problem is Quality and Patient Safety are part of the same system, no matter what the title on the door.

For more ideas on how to handle this see Ed’s Skompki’s Video (just interchange the words Sentinel and Quality):

Read the article here:

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