Board of Commissioners Affirms Support For Sentinel Event Policy

At its April 24-25 meeting, the Joint Commission's Board of Commissioners approved the following:

• A more detailed definition of sentinel event occurrences reportable to the Joint Commission on a voluntary basis.
• Procedural revisions to assist organizations in complying with the policy.
• Initial remedial strategies to minimize the risk of discoverability of information relating to sentinel events.
• Continued exploration of mechanisms to close identified gaps in confidentiality protections.
• A provision for the on-site review of root cause analyses or relevant information.
• A 30-day period (from date of sentinel event or becoming aware of it) to submit root cause analysis for organizations that do not voluntarily self report.

The Board affirmed its support for the Sentinel Event Policy and underscored the need for organizations to conduct root cause analyses of sentinel events and other significant occurrences to improve performance. The intent of these revisions is to minimize the risk of additional liability exposure. The more precise definition will provide a framework for education in health care organizations and for scientific research on the demographics, epidemiology, and prevention of sentinel events.

John Leech, chairman of the Sentinel Event Legal Issues Task Force, presented an interim report to the Board that principally addressed the potential remedial strategies that might be employed to minimize the risk of discoverability of specific information pertaining to a sentinel event. The Board acknowledged the efforts of the Task Force and requested that it assist in the 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. The Joint Commission is committed to working with state hospital associations, state and federal legislators, and other interested parties to develop permanent solutions to this issue. The Task Force will also continue to explore mechanisms for closing identified gaps in confidentiality protection which remain unresolved.

To address current concerns about the possible waiver of legal protection for root cause analyses that are sent to the Joint Commission, the Board authorized the on-site review of root cause analyses for sentinel events or on-site interviews with review of relevant documentation to verify the appropriate analysis of the sentinel event. The on-site reviews will be conducted by specially trained Joint Commission surveyors. These options will become available on July 1, 1998, and the one-day visits will be charged at a rate of $2,300, which reflects only the average direct costs for these reviews. The Board views these options as interim measures until acceptable legal protections for root cause analyses are in place. 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, risks the loss of accreditation.

In addition, the Board approved a modification to the procedures that allows an organization, which has not voluntarily self reported, 30 days from the date of a reportable sentinel event, or of its becoming aware of the event, to complete an acceptable root cause analysis without the risk of being placed on Accreditation Watch. Thus, the time frame provided for completion of a root cause analysis is the same whether an organization chooses to self report or not. The Board emphasized that the objective of the Sentinel Event Policy is to improve patient care through gaining and sharing knowledge about sentinel events and their prevention. The Board views this as a fundamental accountability of the Joint Commission and the organizations that it accredits. The Joint Commission will keep accredited organizations apprised through the periodic distribution of Sentinel Event Alert.

Finally, the Board expressed its commitment to continue to obtain input from key stakeholders -- including consumer representatives, health care organizations and public trust institutions -- concerning the application and further refinement of the Sentinel Event Policy and its related procedures.

Revised Sentinel Event Definition

The Board approved the revised following criteria to define the subset of sentinel events that are reportable to the Joint Commission on a voluntary basis under the Joint Commission's Sentinel Event Policy. Only those sentinel events that affect recipients of care (patients, clients, residents) and that meet the following criteria fall into this category. The Sentinel Event Policy applies only to events that meet the following criteria:

The event 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, (1) , (2) or

The event is one of the following (even if the outcome was not death or major permanent loss of function):

• Suicide of a patient in a setting where the patient receives around-the-clock care (e.g., hospital, residential treatment center, crisis stabilization center)
• Infant abduction or discharge to the wrong family
• Rape (3)
• Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
• Surgery on the wrong patient or wrong body part (4)

Sentinel Event Standards Approved For Field Review

The Standards and Survey Procedures Committee of the Board of Commissioners has approved for field review a proposed new standard and intent statement that requires each accredited organization to have a mechanism for the identification and management of sentinel events. To emphasize the importance of the role of the organization's leadership in establishing a culture conducive to the identification, reporting, analysis and prevention of sentinel events, the new standard is proposed for inclusion in the Leadership chapter titled "Leader's Role In Improving Performance." A sampling of accredited hospitals and home care organizations, and all other accredited organizations should receive the information for review by early summer.

Accreditation Committee To Review Sentinel Event Examples

At a future meeting, the Accreditation Committee of the Board of Commissioners will review specific examples of sentinel events that are and are not subject to review by the Joint Commission under the Sentinel Event Policy. Upon final approval by the committee, copies of the examples will be made available to all accredited organizations.

Hotline Reminder

The Sentinel Event Hotline is now in operation through the Joint Commission's Office Of Quality Monitoring. The number is (630) 792-3700. Through this one number, customers are provided several options relating to sentinel events, including:

• To speak with a member of the Joint Commission staff regarding the Sentinel Event Policy
• To request a sentinel event reporting form
• To receive an update on the status of a current sentinel event report

The hotline is staffed from 8:30 a.m. to 5 p.m. Central Time, Monday through Friday.

Footnotes

1. A distinction is made between an adverse outcome that is related to the natural course of the patient's illness or underlying condition (not reportable) and a death or major permanent loss of function that is associated with the treatment, or lack of treatment, of that condition (voluntarily reportable).
2. "Major permanent loss of function" means sensory, motor, physiologic, or intellectual impairment not present on admission requiring continued treatment or life-style change. When "major permanent loss of function" cannot be immediately determined, reporting is not expected until either the patient is discharged with continued major loss of function, or two weeks have elapsed with persistent major loss of function, whichever occurs first.
3. The determination of "rape" is to be based on the health care organization's definition, consistent with applicable law and regulation. Reporting of an allegation of rape is not expected. The five-day time frame for voluntarily reporting begins when a determination is made that a rape has occurred. Reporting of a rape is not expected where such reporting is prohibited by law.
4. All events of surgery on the wrong patient or wrong body part are voluntarily reportable, regardless of the magnitude of the procedure.

Please route this issue to appropriate staff within your organization. Sentinel Event Alert may only be reproduced in its entirety and credited to The Joint Commission.