Abstract
Sentinel events, that is, events whose single occurrence is of sufficient concern to trigger systematic response, recently were advocated as an important component in managing quality under Continuous Quality Improvement (CQI). Ideally, sentinel events are exceedingly rare and invariably indicate preventable deficiencies (eg, operation on the wrong patient, which should never occur, denotes a lack of management control requiring corrective action). However, although single cases of nosocomial group A streptococcal surgical wound infection or of tuberculosis are harbingers of worse to come unless prompt intervention is initiated, sentinel events generally have not served infection surveillance programs adequately. This is because nosocomial infection is the result of multifactorial chains of events that produce a probability, not a certainty, of infection, and our knowledge is incomplete. Without detailed knowledge of these probabilistic chains, the absolute minimum rates of infection that may be attained, and the optimal statistical approaches to define predictive outbreak “warning” or “action” levels, we will not be able to define meaningful sentinel events. How, then, can we best assure health services quality?Nearly 30 years ago, Drucker suggested that three elements comprise effective management decisions. They involve determining 1) whether a specific situation is generic or an exception, 2) clear specification of what the decision has to accomplish, and 3) what is right rather than simply what is acceptable.
Publisher
Cambridge University Press (CUP)
Subject
Infectious Diseases,Microbiology (medical),Epidemiology
Reference17 articles.
1. Process control for short and small runs;Pyzdek;Quality Progress,1993
2. Detection of aberrations in the occurrence of notifiable diseases surveillance data
3. Nosocomial Infection Surveillance Programs
4. Guidelines for investigating clusters of health events;MMWR,1990
Cited by
2 articles.
订阅此论文施引文献
订阅此论文施引文献,注册后可以免费订阅5篇论文的施引文献,订阅后可以查看论文全部施引文献