JCAHO now requires sentinel event reports
January 1, 2000 2 minutes read
JCAHO now requires sentinel event reports
Quality managers will need to be more alert than ever when it comes to medication errors and other problems that occur while patients receive home care services.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) of Oakbrook Terrace, IL, has implemented its sentinel event standard beginning this month. The standard requires JCAHO-accredited agencies to document a definition of the term "sentinel event," and report all such incidences to appropriate managers and government entities. Home care agencies also need to conduct a route-cause analysis and develop risk-reduction plans, as well as develop an action plan that measures the effectiveness of the process and system improvements to reduce risk.
Joint Commission surveyors will assess an agency’s compliance with that standard through interviews with leaders and staff, performance improvement plans and procedures, measurement and analysis reports of those performance improvement activities, and reviewing action plans regarding sentinel events.
Agencies that fail to satisfy the Joint Commis-sion’s sentinel events requirement could be placed on an "accreditation watch," which would be listed in their public information.
Home care agencies have far fewer sentinel events than other health care settings, according to Joint Commission statistics. From January 1995 to Oct. 28, 1999, the Joint Commission reported 655 sentinel events that JCAHO had reviewed. Of those, only 11, or 1.7%, involved home care agencies.
General hospitals accounted for 417, or 63.7%, followed by psychiatric hospitals with 198 or 16.5%. The third-highest number of sentinel events occurred in hospitals’ psychiatric units, which accounted for 46 events — 7% of the total. This was followed by long-term care facilities with 27, or 4.1%; emergency departments with 19, or 2.9%, and behavioral health facilities with 17, or 2.6%.
The settings that had fewer reported sentinel events than home care agencies were ambulatory care settings with only seven, or 1.1%; clinical laboratories with two, or 0.3%; and health care networks with one, or 0.2%.
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