JCAHO's sentinel event policy: What every ED nurse should know
A Risk Management Update
By Sue Dill Calloway RN, MSN, JD, Director of Risk Management, Ohio Hospital Association, Columbus, OH
Q: What constitutes a sentinel event according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)?
A: There are approximately 5200 hospitals in the United States that are accredited by JCAHO. Any emergency department (ED) nurse who works for a JCAHO accredited facility should be aware of the sentinel event standard.
A sentinel event is an event that has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition. In other words, it is an unexpected incident.
One of the best ways to understand a sentinel event is to look at examples of what are and are not sentinel events. The JCAHO recently published a new list of examples. Some of the examples of a sentinel event include: 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 there is around-the-clock care, any procedure on the wrong patient, any intrapartum maternal death, a patient fall that results in death or major loss of function as a direct result of the injuries sustained in the fall, and a hemolytic blood transfusion reaction involving major blood group incompatibilities.
Examples of non-sentinel events are: any "near miss," return of full limb or bodily function to the same level as prior to the adverse event by discharge or two weeks after the initial loss, any sentinel event that has not affected a recipient of care (patient, resident, client), medication errors that do not result in death or major loss of function, unsuccessful suicide attempts, retained foreign bodies without major loss of function, or minor degree of hemolysis with no clinical sequelae.
An ED nurse should check to see if the facility has a policy and procedure on what to do if a sentinel event occurs. Most facilities have a policy and procedure that outlines the steps a nurse is to take if a sentinel event policy occurs. Some policies require notification of the nursing supervisor or risk management. Some require the completion of a report such as an incident, occurrence, or sentinel event form.
It is important to timely notify the proper person since the facility only has 45 days to complete what is known as a thorough and credible root cause analysis (RCA). A RCA is a risk management tool or process for identifying the basic or causal factors that result in variation in performance. In other words, it looks into things such as what caused the problem, why it occurred, and how it could be prevented. The focus is on systems and processes and not individual performance. For example, an ED nurse accidentally administers 40 meq. of KCL IV. The solution is not to fire the nurse but to put into place a system where this incident does not frequently occur. This is why more than half of the hospitals in the country have taken potassium chloride off the shelves. A K-rider has to be prepared in pharmacy or KCL is either in premixed IV bags or prepared by pharmacy.
It was mentioned that timely reporting is necessary to risk management or the specified individual so the RCA can be completed within the 45-day requirement. Hospitals and other accredited facilities who do not complete the RCA within this time frame are at risk for being placed on accreditation watch by the Joint Commission.
Reporting of sentinel events remains voluntary. Most facilities do not self report to the Joint Commission because of legal concerns that their state peer review statute veil of protection would be pierced and that the report could be discoverable by the plaintiff's attorney in a malpractice case.
Several steps are being taken to minimize this risk. Hospitals will soon be given four options to select based on their state's statute (law) and case law. Also a federal statute has been introduced into Congress to protect the RCA from discovery but this bill has not been passed.
The fourth highest number of sentinel events have occurred in the ED. Of the 257 sentinel events reported to the JCAHO; 153 occurred in general hospitals, 55 in psychiatric hospitals, 21 on the psych unit, and 12 in the ED. The JCAHO recently reported that there have been 257 sentinel events reviewed by the accreditation committee of JCAHO. These include; 52 inpatient suicides, 47 events relating to medication errors, 22 deaths related to delay in treatment, 17 operative/post op complications, 15 events of surgery on the wrong side, 14 restraint deaths, 13 patient elopements, 11 assault/rape/homicide, nine transfusion related deaths, six patient falls (multi-story), five infant abductions/wrong discharge, five maternal deaths, and five events involving medical gas systems.
The Joint Commission is publishing sentinel event alerts to keep hospitals and others informed of changes. There are five sentinel event alerts issued to date. The web address is http://www.jcaho.org. Click on the middle picture, which is the section of health care organizations and professionals. Next click on sentinel event. The date of each alert is on the left hand side. A table of contents includes other resources on sentinel event issues. The JCAHO also has a sentinel event hotline to answer any questions on the sentinel event policy. The number is (630) 792-3700.
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