JCAHO revises guidelines for sentinel events
Nearly everyone has found the Joint Commission's sentinel event policy to be about as clear as swamp water.
It's changed several times in the last few months, and even the experts who keep up with such changes have had a difficult time pinpointing exactly what home care agencies and other health care organizations are being asked to do.
So Homecare Quality Management asked the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, for some guidelines to the policy. Here's how the Joint Commission explains it:
· The Joint Commission's Sentinel Event Policy is designed to encourage the self-reporting of medical organizations' errors in order to learn about the relative frequencies and underlying causes of sentinel events, to share the lessons learned with other health care organizations, and to reduce the risk of future sentinel event occurrences.
· By addressing the issue of medical errors, the Joint Commission seeks to strike a balance between the public's expectations of a credible accreditation process and the practical needs of health care organizations.
· This policy provides an opportunity to expand the Joint Commission's database of sentinel events that occur with significant frequency. The database also will categorize the most common underlying causes of these events. This information will be distributed to the health care community to reduce the frequency of medical errors.
· A sentinel event is any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injuries specifically include a loss of limb or function.
· Any time a sentinel event occurs, the accredited organization is expected to complete a thorough and credible root-cause analysis, implement improvements to reduce risk, and monitor the effectiveness of those improvements.
· The Joint Commission's approach to sentinel events echoes the call of the National Patient Safety Foundation of the American Medical Association for protected venues that encourage the self-reporting of errors as a first step in their reduction.
· Any accredited health care organization that experiences a sentinel event and voluntarily notifies the Joint Commission within five business days of its occurrence (or within five days of learning of its occurrence) will not be placed on accreditation watch if it subsequently submits to the Joint Commission an acceptable root-cause analysis within 30 days.
· If the Joint Commission receives an inquiry about the accreditation status of an organization during the 30-day root-cause analysis period, the organization's accreditation status will be reported in the usual manner without reference to the sentinel event. If an inquirer specifically references the sentinel event, the Joint Commission will acknowledge that it is working with the organization through its sentinel event review process.
· The reporting of sentinel events is voluntary, but accredited organizations are required to conduct root-cause analyses any time a sentinel event occurs. While most sentinel events are caused by human error, the root-cause analysis is expected to dig down to underlying organization systems and processes that can be altered to reduce the likelihood of human fallibility in the future.
· An organization that chooses not to report a sentinel event will not be placed on accreditation watch if, upon Joint Commission inquiry, it has performed a thorough and credible root-cause analysis and makes that information available to the Joint Commission. If the Joint Commission determines there is significant potential for an ongoing risk to patient health or safety, or the likelihood exists of continuing significant non-compliance with important Joint Commission standards, an on-site review will be conducted by a single surveyor for a flat fee of $3,500.
· An organization that does not self-report has 30 days from the date of the sentinel event to complete an acceptable root-cause analysis without the risk of being placed on accreditation watch.
· Accreditation watch is a publicly disclosable attribute of an organization's existing accreditation status and it signifies that an organization is under close monitoring by the Joint Commission. The accreditation watch is removed once an organization completes and submits an acceptable root-cause analysis.
· The Joint Commission will not disclose legally protected sentinel event-related information to any third party and will vigorously defend the legal confidentiality of this information, if necessary, in the courts.
· The Joint Commission has initiated these procedures to protect the confidentiality of sentinel event information:
- The Joint Commission advises health care organizations not to provide patient or caregiver identifiers when reporting sentinel events.
- An organization that experiences a sentinel event should submit these two documents to the Joint Commission: (a) the root-cause analysis; (b) the resulting action plan. The root-cause analysis will be returned to the organization once abstracted information is entered into the Joint Commission database. Any copies made for internal review will be destroyed after the review. Also, once the action plan has been implemented to the Joint Commission's satisfaction, it will be returned to the organization.
- Health care organizations may request an on-site review of a root-cause analysis for a sentinel event, beginning July 1, 1998.
· To protect the confidentiality of sentinel event-related information, the Joint Commission will include language in future contracts between the Joint Commission and accredited organizations that will formally recognize the Joint Commission as a participating entity in the organization's quality monitoring and improvement activities. In this context, the Joint Commission will be explicitly portrayed as part of, not separate from, the organization in working to reduce the risk of future sentinel events.
· A Sentinel Events Legal Issues Task Force has addressed the potential remedial strategies that might be employed to minimize the risk of discoverability of specific information pertaining to a sentinel event. The task force intends to assist the Joint Commission in pursuit of federal legislation and development of model state legislation that would reinforce existing protections for sentinel event-related information that may be shared with the Joint Commission by health care organizations.
· If an organization declines to share any information regarding a sentinel event with the Joint Commission, the organization will be placed on accreditation watch, and ultimately, risk the loss of accreditation.
· A Joint Commission hotline will answer questions about sentinel events. Call (630) 792-3700.
· A new periodic publication, Sentinel Event Alert, is being distributed to all accredited organizations, and it will focus on providing important information relating to the occurrence and management of sentinel events.
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