Good morning, members of the board. My name is [Your Name], and I serve as your Chief Safety and Risk Management Officer. I’m here today to provide a transparent and comprehensive account of a recent sentinel event that led to sanctions from both our accrediting body and a state regulatory agency. This presentation will cover the incident’s specifics, the regulatory standards we failed to meet, the root causes, and our actionable plan to prevent a recurrence.

Slide Presentation Outline: Incident Sanctioned by Regulatory Bodies

Slide 1: Title Slide

• Title: A Critical Review of Our Quality and Safety Deficiencies
• Subtitle: An Account of a Recent Sanctioned Incident
• Prepared for: The Board of Directors
• Presented by: [Your Name], Chief Safety & Risk Management Officer

Slide 2: Executive Summary of the Incident

• Incident Description: A 75-year-old male patient, Mr. Smith, was admitted to our facility for routine outpatient cataract surgery on his left eye. Due to a series of procedural breakdowns, the surgical team performed the surgery on the patient’s right eye.
• Outcome: The error was discovered post-procedure by a recovery room nurse who reviewed the patient’s chart. While the patient was not physically harmed, the psychological distress and loss of trust led to a formal complaint to the state board of health and a report to The Joint Commission (TJC). The complaint resulted in a public sanction from the state and a preliminary denial of accreditation from TJC.
• Sanction: Our facility was placed on a “Preliminary Denial of Accreditation” status by The Joint Commission and received a financial penalty from the state’s Department of Health for violating patient safety protocols.

Slide 3: The Regulatory Framework

• The Joint Commission (TJC): As our primary accrediting body, TJC holds us to stringent standards for quality and safety. The specific violated standard was NPSG.01.01.01, which requires us to use at least two patient identifiers when providing care, treatment, and services. The incident also violated Universal Protocol, which mandates a pre-procedure verification process, marking the procedure site, and a time-out before the start of the procedure.
• State Department of Health (DOH): The DOH, as a regulatory body, holds us accountable for state-level licensing and certification standards. The sanction was a result of a violation of a state-specific surgical safety protocol, which aligns with TJC’s Universal Protocol, leading to a public finding of non-compliance.
• CMS (Centers for Medicare & Medicaid Services): Since TJC accreditation is tied to our ability to receive Medicare and Medicaid reimbursement, our preliminary denial of accreditation puts our funding and financial viability at severe risk.

Slide 4: The Critical Mistakes and Oversights

• Lack of Adherence to Universal Protocol: The surgical team failed to perform a mandatory pre-procedure “time-out” verification, which is designed to confirm the correct patient, procedure, and site. This was a critical failure of a standard, well-established safety protocol.
• Communication Breakdown: There was a breakdown in communication between the pre-operative nurse, the surgeon, and the surgical team. The pre-op nurse noted the correct eye on the chart but failed to verbally confirm it with the surgeon.
• Process “Normalization of Deviance”: The surgical team had developed a culture of “normalization of deviance,” where they occasionally bypassed or rushed through safety checks due to time pressures. This was a silent, systemic problem that contributed directly to the incident.

Slide 5: Preventive Steps That Could Have Been Taken

• Enforce a “No-Exceptions” Policy for Universal Protocol: Leaders should have strictly enforced the “time-out” and surgical site verification protocols with zero tolerance for deviations.
• Implement a Robust Pre-Surgical Checklist: A more detailed, mandatory checklist could have served as a final failsafe, requiring sign-offs from all team members before the first incision.
• Foster a Culture of Psychological Safety: Staff should have felt safe to speak up without fear of retribution if they noticed a discrepancy. Our organizational culture failed to empower all team members to halt a procedure if they felt a safety risk existed.

Slide 6: Education and Training Proposal

• Mandatory Recertification: All surgical and pre-operative staff will undergo mandatory re-certification in our surgical safety protocols, with a special emphasis on Universal Protocol and the use of the surgical checklist.
• Simulation-Based Training: We will implement quarterly simulation training for surgical teams using high-fidelity mannequins and role-playing scenarios to practice safe communication, error-prevention, and team-based problem-solving.
• Interdisciplinary Communication Workshops: We will conduct regular workshops to improve interdisciplinary communication, focusing on techniques like “call-out” and “check-back” to ensure critical information is received and understood.

Slide 7: Continuous Quality Improvement (CQI)

• Just Culture: We will adopt a Just Culture framework, where staff are encouraged to report errors and near-misses without fear of reprisal. This will allow us to identify system failures, rather than just blaming individuals.
• Root Cause Analysis (RCA): Every patient safety incident will trigger a Root Cause Analysis team composed of multi-disciplinary staff to identify the underlying system issues, not just the individual mistakes.