The Joint Commission’s Sentinel Event Policy is designed to improve patient safety in all health care organizations by working with and learning from organizations that experience serious adverse events in patient care. The policy encourages the self-reporting of sentinel events to The Joint Commission that enables it to learn about the relative frequencies and underlying causes of sentinel events and to share “lessons learned” with other health care organizations, thereby reducing the risk of future sentinel events in other organizations.
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. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. When a sentinel event occurs, the accredited organization is required to complete a thorough and credible root cause analysis, implement improvements to reduce risk and monitor the effectiveness of those improvements. A standard that creates explicit expectations regarding the internal identification and management of sentinel events is found in the Improving Organization Performance (PI) chapter of all accreditation manuals.
The Joint Commission database of reviewed sentinel events categorizes the most common underlying causes of these events and the strategies that accredited organizations have used to reduce risk to patients. The Joint Commission regularly distributes to health care organizations information about specific types of sentinel events and how they can be prevented through its newsletter, Sentinel Event Alert. The Sentinel Event policy, statistics from the sentinel event database, and issues of Sentinel Event Alert are available on The Joint Commission’s website at www.jointcommission.org/SentinelEvents.
Reviewable sentinel events
Under the Sentinel Event Policy, a defined subset of sentinel events is subject to review by the Joint Commission and may be reported to The Joint Commission on a voluntary basis. These are sentinel events that affect recipients of care and that result in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition, or is one of the following (even if the outcome was not death or major permanent loss of function):
- Suicide of any individual receiving care, treatment or services in a staffed around-the-clock care setting, or within 72 hours of discharge
- Unanticipated death of a full-term infant
- Abduction of any individual receiving care, treatment or services
- Discharge of an infant to the wrong family
- Rape
- Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
- Surgery on the wrong individual or wrong body part
- Unintended retention of a foreign object in an individual after surgery or other procedure
- Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
- Prolonged fluoroscopy with cumulative dose >1500 rads to a single field, or any delivery of radiotherapy to the wrong body region or 25 percent above the planned radiotherapy dose
Each accredited health care organization is encouraged, but not required, to report to The Joint Commission any sentinel event meeting these criteria for reviewable sentinel events. The Joint Commission may become aware of a reviewable sentinel event by some other means, such as from a patient, family member or employee of the organization, or through the media. Whether the organization voluntarily reports the event or The Joint Commission becomes aware of the event by some other means, there is no difference in the expected response, time frames or review procedures. An event that occurred more than one year before The Joint Commission became aware of the event will not, in most cases, be reviewed under the Sentinel Event Policy. In such a case, a written response will be requested from the organization, including a summary of processes in place to prevent similar occurrences.
Required response to a reviewable sentinel event
If The Joint Commission becomes aware (either through voluntary self-reporting or otherwise) of a sentinel event that meets the definition of a reviewable sentinel event, the organization is required to prepare a thorough and credible root cause analysis and action plan and submit them to The Joint Commission. Or, the organization must provide for Joint Commission evaluation of its response to the sentinel event under an approved protocol, within 45 calendar days of the known occurrence of the event. The Joint Commission will then determine whether the root cause analysis and action plan are acceptable. If the determination that an event is reviewable under the Sentinel Event Policy occurs more than 45 calendar days following the known occurrence of the event, the organization will be allowed 15 additional calendar days for its response. Failure to submit the root cause analysis and action plan in the expected time frame can result in a change to the organization’s accreditation status.
Advantages to reporting a sentinel event
There are several advantages to reporting a sentinel event.
- Reporting the event enables the addition of the “lessons learned” from the event to be added to The Joint Commission’s sentinel event database, thereby contributing to the general knowledge about sentinel events and the reduction of risk for such events in other organizations.
- Early reporting provides an opportunity for consultation with Joint Commission staff during the development of the root cause analysis and action plan.
- The organization’s message to the public that it is doing everything possible to ensure that such an event will not happen again is strengthened by its acknowledged collaboration with The Joint Commission to understand how the event happened and what can be done to reduce the risk of such an event occurring in the future.
Survey process
If, in the course of conducting the usual survey activities, a sentinel event is identified, the surveyor will take the following steps:
- Inform the CEO that the event has been identified
- Inform the CEO the event will be reported to The Joint Commission for further review and follow-up under the provisions of the Sentinel Event Policy.
During the on-site survey, the surveyor will assess the organization’s compliance with sentinel event-related standards by reviewing the organization’s process for responding to a sentinel event, interview the organization’s leaders and staff about response to sentinel events and ask for an example of a root cause analysis that has been conducted in the last year. In selecting an example, the organization may choose a “closed case” or a “near miss” to demonstrate its process for responding to a sentinel event.
Disclosable information
If The Joint Commission receives an inquiry about the accreditation decision of an organization that has experienced a reviewable sentinel event, the organization’s accreditation decision will be reported in the usual manner without reference to the sentinel event. If an inquirer specifically references a sentinel event under review, The Joint Commission will acknowledge that it is aware of the event and currently is working or has worked with the organization through the sentinel event review process.
Submission of root cause analysis and resulting action plan
An organization that experiences a sentinel event is asked to submit two separate documents to The Joint Commission: the root cause analysis and the resulting action plan via the electronic root cause analysis tool accessed via the secure extranet site. The root cause analysis and action plan are not to include the name(s) of caregivers or patients involved in the sentinel event.
Alternatively, if the organization has concerns about possible waiver of confidentiality protections as a result of sending the root cause analysis documents to The Joint Commission, the following alternative approaches to review of the organization’s response to the sentinel event are acceptable:
- An organization brings root cause analysis documents to The Joint Commission headquarters for review and takes the documents back on the same day.
- A sentinel event specialist or specially trained surveyor conducts an on-site visit to review the root cause analysis and action plan documents.
- A sentinel event specialist or specially trained surveyor conducts an on-site visit to review the root cause analysis and findings, and action plan documents, without directly viewing the root cause analysis documents, through a series of interviews and review of relevant documentation.
- When the organization affirms that it meets specified criteria respecting the risk of waiving legal protections for root cause analysis information shared with The Joint Commission and attests that a thorough and credible root cause analysis has been conducted for the sentinel event under review, an onsite visit by a specially trained surveyor is scheduled to evaluate the organization’s process and the adequacy of the organization’s response.
Follow-up activities
After The Joint Commission has determined that an organization has conducted an acceptable root cause analysis and developed an acceptable action plan, The Joint Commission will notify the organization that its root cause analysis and action plan are acceptable and will assign an appropriate follow-up activity, typically one or more sentinel event measures of success due in four months.
Handling sentinel event-related documents
Handling of any submitted root cause analysis and action plan is restricted to specially trained Joint Commission staff in accordance with procedures designed to protect the confidentiality of the documents. Upon completion of The Joint Commission review of any submitted root cause analysis, action plan, and the subsequent sentinel event measures of success, and the abstraction of the required data elements for The Joint Commission’s Sentinel Event Database, the original root cause analysis will be de-identified. Upon request, any supporting documents that were submitted as an adjunct to the electronic root cause analysis will be returned to the organization.
Confidentiality of information
The Joint Commission continues to pursue federal and state legislation that would reinforce existing protections for sentinel event-related information that health care organizations may share with The Joint Commission. The Joint Commission also has identified two contractual arrangements that should substantively address the legal concerns regarding potential waiver of confidentiality protections in certain states. These arrangements involve having the health care organization either identify, through written agreement, The Joint Commission as a participating entity in the organization’s peer review or quality improvement activities; or appoint The Joint Commission to the organization’s peer review or quality improvement committee. These arrangements clarify that The Joint Commission is not an external third party in the limited context of an intensive assessment of a sentinel event and, therefore, no waiver of confidentiality protections has occurred by sharing sentinel event-related information with The Joint Commission.
For more information
Call the sentinel event hotline at (630) 792-3700, or visit The Joint Commission’s website, www.jointcommission.org.
3/08