Sentinel event policy unfolds; stay tuned
May 1, 1998 3 minutes read
Sentinel event policy unfolds; stay tuned
Nonreporting, noncompliant hospitals at risk
Don't let your guard down. The dust is far from settled surrounding the revised sentinel event policy put in place April 1 by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL.
For now, self-reporting of sentinel events is voluntary, but root-cause analyses (RCAs) are required any time a sentinel event occurs. (See Patrice Spath's article on RCAs, p. 95.) When an organization experiences a sentinel event, it is not required to report it to the Joint Commission, but it is expected to complete the RCA. If the RCA is later deemed acceptable by the Joint Commission, that facility is not placed on watch. If it does not report the event, however, and is later found not to have completed an RCA, it is at risk for being placed on accreditation watch, making its information disclosable. The previous policy automatically placed such a facility on watch. Similarly, if an organization fails to perform and submit an RCA within 30 days of the event, it waives confidentiality protection.
If an organization fails to report a known sentinel event within five business days or to complete and submit an RCA within 30 days, it becomes subject to immediate or follow-up site evaluations. Those failures also could result in change or loss of accreditation. Each event evaluated will be reviewed at the next full survey, and the review will focus on how effectively risk-reduction activities are being sustained.
The revised policy specifies that an accredited institution that reports a sentinel event within five business days of its occurrence will have its information protected and will not be placed on accreditation watch. Previously, the provider's sentinel event would be disclosed as a matter of public record when the Joint Commission put the organization on accreditation watch status. If the Joint Commission receives an inquiry about the accreditation status of an organization during the 30-day RCA period, it reports the accreditation status in the usual manner without any reference to the sentinel event.
Be aware of this caveat, however: If the inquirer refers specifically to the sentinel event, the Joint Commission will acknowledge it is working with the provider through its sentinel event process. The organization will not be subject to an immediate on-site review, as previously required, unless the accrediting body determines that a potential ongoing threat to patient safety exists; in that case, a review will be ordered and will cost $3,500.
Definition will soon be a little clearer
The Joint Commission previously defined a sentinel event as "any unexpected occurrence involving death or serious physical or psychological injury or the risk thereof." The new policy says these incidents automatically are classified as sentinel events:
· infant abduction;
· infant discharge to the wrong family;
· rape by a patient or staff member;
· transfusion reaction from mismatched blood;
· surgery on the wrong patient or body part.
"Serious" injuries include loss of limb or limb function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. However, the sentinel event policy is invoked only if the sentinel event actually results in an unanticipated death or major permanent loss of function.
As of Jan. 1, 194 sentinel events were reviewed by the accrediting committee. Of these, 115 took place in general hospitals, 41 in psychiatric hospitals, and the remainder in other facilities monitored by the Joint Commission. Of those, 39 were deemed to be the result of medicine errors, 34 were inpatient suicides, and 15 were deaths related to delay in treatment.
[Editor's note: The Joint Commission intends to develop a central hotline that hospital leaders can call to get consistent responses to their questions about sentinel events. Meanwhile, you can call Rick Croteau, (630) 792-5776, Glenn Krasker, (630) 792-5810, or Gail Weinberger, (630) 792-5766, all at the Joint Commission, when uncertainties exist. Sentinel events should be reported to the Office of Quality Monitoring, (630) 792-5642.]
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