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The paper explored the extent to which hospital appointed official root cause analysis (RCA) panels consider antecedent and proximal events when they investigate communication related sentinel events (CRSEs) in hospitals. It also explored which CRSEs are most common in the hospital setting in Hong Kong and the communication modes most commonly associated with CRSEs. The data consisted of Risk Alert and Annual Report on SEs issued by the Hong Kong Hospital Authority from October 2007 to September 2017. Over the period studied, there were 379 reported sentinel events (SEs). In 186 of these SEs we identified communication as a contributing factor. We examined the RCA panels’ reports on contributing factors and subsequent recommendations in these 186 SEs and found that their recommendations only highlighted the proximal contributing factors and not antecedent factors that may be relevant. RCA panels most often recommended that communication should be enhanced or documentation improved. We propose that it is time to review the RCA process to recognize that many CRSEs may occur because of antecedent factors that result from the complex hospital organizational structure and its associated hierarchical culture. We suggest two ways forward, 1) applying a language and social psychology perspective to the investigations of CRSEs and, 2) the involvement of experts from different disciplines who can work with clinicians during RCA investigations.

Sentinel Events and Miscommunication What do we know in 2021: A Language and Social Psychology Framework