The use of simulation in causal analysis of sentinel events in healthcare

THE USE OF SIMULATION IN CAUSAL ANALYSIS OF SENTINEL EVENTS IN HEALTHCARE James E. Davis Dana S. Kaminstein Annually, over 200,000 people suffer injury or death due to preventable medical errors. Unintentional medical errors continue to be a problem despite repeated attempts within health care to reduce sentinel events. High Fidelity Medical Simulation (HFMS) provides a realistic, computer generated patient care environment. Simulation has been used successfully to educate and train healthcare providers. Little research has examined how simulation could contribute to the investigation of causal analysis of sentinel events in healthcare. This dissertation addresses the question: How can medical simulation play a role in the understanding of sentinel events in healthcare? Three sentinel event cases were identified and investigated using typical morbidity and mortality (M&MC) methods. Ten contributing factors averaging 3.33 (2–5) were found in each sentinel event through traditional debriefing. Nineteen additional contributing factors were identified through simulation averaging 6.3 (4–7) additional contributing factors. Simulation provided a 65.5% increase in causal factors of sentinel events compared to traditional debriefing. In addition, there were an additional fifty-eight points of learning that were identified through the simulations and debriefings. This research concludes that