• Protect the scene and involved equipment from being disturbed or altered;

• Sequester all involved equipment, medication or supplies, if applicable.

• Perform an immediate, thorough and confidential investigation of the sentinel event;

• Interview all staff (individually) and have them relay the sequence of events as they recall them;

• Conduct the root cause analysis in a non-confrontational, non-judgmental and non-punitive manner;

• Develop and implement an action plan that will reduce the likelihood of such an event from occurring in the future;

• Subject solutions to failure mode, effect, and criticality analysis (FMECA);

• Guide you in reporting the event to the appropriate regulatory and accrediting bodies;

• Shape media and public relations messages;

• Address the psychological and emotional effects that a medical error can have on the involved staff.

2313 North Grant Ave. - Wilmington, DE 19806 - (302) 427.2461 - Fax (302) 427.2320
gkrasker@NoMoreErrors.com