Here's what JCAHO says hospitals should report
Near misses need not be included
The Accreditation Committee of the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has released the following examples of sentinel events considered voluntarily reportable:
· Any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error.
· Any suicide of a patient in a setting where the patient is housed around the clock, including suicides following elopement (unauthorized departure) from such a setting.
· Any elopement of a patient from an around-the-clock care setting resulting in a temporally related death (suicide or homicide) or major permanent loss of function.
· Any procedure on the wrong patient, wrong side of the body, or wrong organ.
· Any intrapartum maternal death.
· Any perinatal death unrelated to a congenital condition in an infant having a birth weight greater than 2,500 grams.
· Assault, homicide, or other crime resulting in patient death or major permanent loss of function.
· A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.
· Hemolytic transfusion reaction involving major blood group incompatibilities.
The following are examples of events that are not reportable:
· Any "near miss."
· Full return of limb or bodily function to the same level as prior to the adverse event by discharge or within two weeks of the initial loss of said function.
· Any sentinel event that has not affected a recipient of care.
· Medication errors that do not result in death or major permanent loss of function.
· Suicide other than in an around-the-clock care setting or following elopement.
· A death or loss of function following a discharge "against medical advice."
· Unsuccessful suicide attempts.
· Unintentionally retained foreign body without major permanent loss of function.
· Minor degrees of hemolysis with no clinical sequelae.
For further information, go to the Joint Commission's Web site, http://www.jcaho.org/pubedmul/publicat/sealert/sea_frm.htm. A Joint Commission hotline is in operation to respond to questions regarding sentinel events. The number is (630) 792-3700.
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