• Section 5. Sentinel Events and Patient Safety

    Joint Commission on Accreditation of Health Care Organizations

    The Joint Commission on Accreditation of Health Care Organizations evaluates and accredits nearly 21,000 healthcare organizations and programs in the United States. An independent, not-for-profit organization, the Joint Commission is the nation’s predominant standards setting and accrediting body in healthcare. Since 1951, the Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by healthcare organizations.

    Joint Commission’s Mission Statement is tocontinuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.”17

    The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements. Joint Commission accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain the Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years.

    Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient care and organization functions that are essential to providing safe, high quality care. Joint Commission standards are developed with input from healthcare professionals, providers, subject matter experts, consumers, government agencies and employers. 

    The standards are informed by scientific literature and expert consensus and approved by the Board of Commissioners. New standards are added only if they relate to patient safety or quality of care, have a positive impact on outcomes, meet or surpass law and regulation, and can be accurately and readily measured.

    The Joint Commission has developed a Sentinel Event Policy and Procedures for the following facilities:


    • Ambulatory Health Care
    • Behavioral Health Care
    • Critical Access Hospital
    • Home Care
    • Hospital
    • Laboratory
    • Nursing Care Center
    • Office-Based Surgery
    • Disease-Specific Care

    Sentinel Event Policy and Procedures

    A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following:18

    • Death
    • Permanent harm
    • Severe temporary harm

    An event is also considered sentinel if it is one of the following: 

    • Suicide of any patient receiving care, treatment, and services in a staffed around-the clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED)
    • Unanticipated death of a full-term infant
    • Discharge of an infant to the wrong family
    • Abduction of any patient receiving care, treatment, and services
    • Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the ED), leading to death, permanent harm, or severe temporary harm to the patient
    • Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups)
    • Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the hospital
    • Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital
    • Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure
    • Unintended retention of a foreign object in a patient after an invasive procedure, including surgery
    • Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
    • Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose


    Such events are considered “Sentinel” because they signal a need for immediate investigation and response. All sentinel events must be reviewed by the hospital and are subject to review by The Joint Commission. Accredited hospitals are expected to identify and respond appropriately to all sentinel events (as defined by The Joint Commission) occurring in the hospital or associated with services that the hospital provides.


    An appropriate response includes all of the following:

     

    A formalized team response that stabilizes the patient, discloses the event to the patient and family, and provides support for the family as well as staff involved in the event Notification of hospital leadership Immediate investigation Completion of a comprehensive systematic analysis for identifying the causal and contributory factors Identification of corrective action to eliminate or control hazards or vulnerabilities directly related to causal and contributory factors

     

    Patient Safety Events

     

    Sentinel events are one category of patient safety events. A patient safety event is an event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient safety events also include adverse events, no-harm events, close calls, and hazardous conditions, which are defined as follows:19


    • An adverse event is a patient safety event that resulted in harm to a patient.
    • A no-harm event is a patient safety event that reaches the patient but does not cause harm.
    • A close call (or “near miss” or “good catch”) is a patient safety event that did not reach the patient.
    • A hazardous (or “unsafe”) condition(s) is a circumstance (other than a patient’s own disease process or condition) that increases the probability of an adverse event.

    The hospital determines how it will respond to patient safety events that do not meet The Joint Commission’s definition of sentinel event. Adverse events require prompt notification of hospital leaders, investigation of the event, and corrective actions implemented, in accordance with the hospital’s process for responding to patient safety events that do not meet the definition of a sentinel event. An adverse event may or may not result from an error.

     

    No-harm events, close calls, and hazardous conditions are tracked and used as opportunities to prevent harm, in accordance with the hospital’s process for responding to patient safety events that do not meet the definition of sentinel event.

     

    Comprehensive Systematic Analysis

     

    As indicated above, appropriate response to a sentinel event includes the completion of a comprehensive systematic analysis for identifying the causal and contributory factors. Root cause analysis, which focuses on systems and processes, is the most common form of comprehensive systematic analysis used for identifying the factors that underlie a sentinel event.

     

    Action Plan Requirement

     

    The product of the comprehensive systematic analysis is an action plan. The action plan identifies the strategies that the hospital intends to implement in order to reduce the risk of similar events occurring in the future. The plan must address the following:


    • Responsibility for implementation
    • Time lines for completion
    • Strategies for evaluating the effectiveness of the actions
    • Strategies 

    Seminal Event Occurrence, Settings & Outcomes


    This sentinel event-related data, reported to The Joint Commission from their accredited organizations, demonstrates the need of the Joint Commission and accredited healthcare organizations to continue to address these serious adverse events.


    By identifying causes, trends, settings and outcomes of sentinel events, The Joint Commission can provide critical information in the prevention of sentinel events to accredited healthcare organizations and the public.

     

    The following chart summarizes the Total number of Sentinel Events reviewed by The Joint Commission 1995 through 3Q 2015.



    The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events.20

    The majority of sentinel events occur in hospitals. There were a total of 6,248 general hospital sentinel events reported as of September 2015.

    The following chart shows the number and percentage of the total sentinel events listed by type of facility.


    The Sentinel Event Outcomes show that 57% led to a patient death and another 26.5% lead to unexpected additional care.

    The following chart shows the Type of Sentinel Events.  An interesting point is that the wrong-patient, wrong-site, wrong procedure remains the number one reported medical error.



    CASE STUDY #6

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Section 4. Case Study IllustrationsSection 6. National Patient Safety Goals