When different organizations, merged with CIUSSS, we wanted to inform their directors and CEOs of all sentinel events. Furthermore, we wanted to set up a system, which would allow us to process such events quickly, and avoid their re-occurrence in the future. The risk management team, which was set up as a result, had to cover large distances, extending to the entire Saguenay–Lac-Saint-Jean region (96,000 km2). Indeed, dealing with such a challenge led us to develop new methods.

First, we had to create a notification system, relying on a sentinel event reporting form, which had to be completed within the 24 hours following the event. Based on a preset procedure, the notification consisted of 2 different routes; the first one led to the management concerned, going as high up as the CEO, whilst the second went to the risk management team and its quality, evaluation, performance and ethics director (the PDGA (PRÉSIDENT-DIRECTEUR GÉNÉRAL ADJOINT) [Vice-President]. The director in question would look into the progress every Tuesday, during the strategic planning meeting, adding missing events, whenever the first route had not been completed.

We also set up an event analysis procedure, based on the lean method. The analysis had to be carried out within 5 business days following the occurrence, with the view to identifying the causes of the event. The procedure would be implemented by field teams, in the presence of an adviser from the DSI (Direction des soins infirmiers) [Directorate of Nursing Care] and DSM (Direction des services multidisciplinaires) [Directorate of Multi-Disciplinary Services] who, if necessary, could extend the scope of recommendations to the entire CIUSSS.

Once the problem was resolved, recommendations were sent to all hierarchical levels of the management concerned.

This system ensured that the information about sentinel events was received promptly by the Management Committee and the CEO and that the impact of such events on users’ safety could be properly assessed and recommendations duly implemented.

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