Organization changes sentinel event definitions
Several important changes were announced to Joint Commission on Accreditation of Health-care Organizations surveyors at a recent training session in Chicago, including new definitions for some types of sentinel events.
The accrediting body also has issued a formal alert to health care providers about the danger of nosocomial infections.
In addition to emphasizing the newly intense focus on infection control, surveyors were told of changes to one sentinel event definition and a new sentinel event type. Mark Forsteneger, Joint Commission spokesman, confirms the announcements to Hospital Peer Review.
Rape already was a sentinel event, but the Joint Commission now has expanded the definition of rape to include "unconsented sexual contact," Forsteneger says. That definition broadens the type of sexual activity that could be considered a sentinel event so that sexual intercourse is not necessary to meet the threshold.
Also, the Joint Commission told surveyors that the "unanticipated death of a full-term infant" now is considered a sentinel event. This is a new addition to the list of events that are automatically considered sentinel events requiring a root-cause analysis and possible report to the agency. Other events are considered on a case-by-case basis using Joint Commission guidelines.
In addition, surveyors no longer will issue supplemental recommendations. Instead, the only options will be a Type I recommendation or what was described as "information finding," though the Joint Commission may end up calling it something else. Unlike supplemental recommendations, which must be addressed or hospitals will get a Type I, there will be no obligation to correct problems in the "information finding."
Surveyors also were told that they must stop the practice of handing out their own forms during the survey process. Many surveyors were in the habit of using their own forms to ask for certain types of information during a survey, just as a matter of expediency and personal preference, but were told during the meeting that they must use only Joint Commission forms to request information.
Alert issued after recent concerns
The Joint Commission also followed its recent statements about the need for improved infection control with a formal alert urging accredited providers to increase reporting of infection-related deaths. Its leaders recently stated that serious nosocomial infections should be considered sentinel events and thoroughly investigated, with Paul Schyve, MD, Joint Commission senior vice president, saying that "If a patient dies in a hospital or has a permanent disability as a result of a nosocomial infection, the hospital really should think about that as a sentinel event and treat it and evaluate as such. When the outcome is that serious, it is not the same as saying let’s add these [infections] up and look for trends and patterns. It is, in fact, a sentinel event."
In response to the Joint Commission’s new position, Patrice Spath, RHIT, a consultant in Forest Grove, OR, advises broadening your definition of what type of nosocomial infection is defined as a sentinel event.
She suggests including an infection control practitioner in the committee or ad hoc group that conducts the preliminary review of adverse events to determine whether a root-cause analysis is necessary. It also can be useful to have physicians to include a question on their mortality review forms about the need to review the nosocomial infection, she says.
To emphasize the Joint Commission’s new approach, it issued a Sentinel Event Alert that says hospital-acquired infections are being "seriously underreported across America." In addition to calling for increased reporting, the Joint Commission is urging better infection control practices. In particular, the Sentinel Event Alert urges compliance with new guidelines from the Centers for Disease Control and Prevention (CDC) that advise health care professionals to use alcohol-based hand rubs (in conjunction with soap and water and sterile gloves) to prevent these acquired infections.
The CDC estimates that more than 2 million patients annually develop infections while hospitalized for other health problems and that nearly 90,000 die as a result of these infections. Despite these high figures, the Joint Commission’s 7-year-old patient safety reporting database includes only 10 such reports that cover 53 patients.
In releasing the alert, Dennis S. O’Leary, MD, president of the Joint Commission, said, "We are receiving a disproportionately low volume of reports on the number of patient deaths from infections acquired in the health care setting, possibly because many health care organizations do not view these events as errors’ under the definition of a sentinel event. However, in view of the importance and high visibility of such occurrences, we are urging health care organizations to share this information with the Joint Commission, just as they might share information about other types of sentinel events with us."
In addition to evaluating compliance with infection control standards during its regular triennial surveys, the Joint Commission has included infection control as a special focus area during random unannounced surveys for hospitals in 2003, he noted. The Joint Commission also is convening a new infection control panel with 20 experts to suggest ways in which current standards can be strengthened.
[For more information, contact:
- Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000.
- Patrice Spath, Brown-Spath & Associates, 2314 19th Ave., Forest Grove, OR 97116. Telephone: (503) 357-9185.]
Several important changes were announced to Joint Commission on Accreditation of Health-care Organizations surveyors at a recent training session in Chicago, including new definitions for some types of sentinel events.
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