Follow-Up Evaluation of Issues Identified in the 2010 Peace Corps/Morocco Assessment of Medical Care

We recommend that the associate director of the Office of Health Services implement a screening process for root cause analyses that considers severity and frequency of negative health outcomes.

We recommend that the associate director of the Office of Health Services ensure staffing is sufficient to adequately implement a more effective sentinel event reporting system and that staff involved in root cause analyses have not had direct involvement in the case.

We recommend that the associate director of the Office of Health Services perform all root cause analyses in a manner that includes key components (system focus, cause/effect, action plan, and measures).

We recommend that the associate director of the Office of Health Services improve staff understanding of best practices for selecting sentinel events for review and for carrying out root cause analyses.

We recommend that the associate director of the Office of Health Services clarify the agency’s policies and procedures related to sentinel event reviews to focus on and address systemic causes.