Accreditation Committee Approves Examples Of Voluntarily Reportable Sentinel Events

At its May 7 meeting, the Accreditation Committee of the Board of Commissioners approved the following examples of sentinel events considered voluntarily reportable under the Joint Commission's Sentinel Event Policy as well as examples of sentinel event that are not considered reportable to the Joint Commission under the policy. Questions regarding the following examples should be directed to the Joint Commission's Sentinel Event Hotline at (630) 792-3700.

Examples Of Sentinel Events That Are Voluntarily Reportable Under The Joint Commission's Sentinel Event Policy

• 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 the patient is housed around-the-clock, including suicides following elopement from such a setting.
• Any elopement, i.e., unauthorized departure, of a patient from an around-the-clock care setting resulting in a temporally related death (suicide or homicide) or major permanent loss of function.
• Any procedure on the wrong patient, wrong side of the body or wrong organ.
• Any intrapartum (related to the birth process) maternal death.
• Any perinatal death unrelated to a congenital condition in an infant having a birth weight greater than 2500 grams.
• Assault, homicide or other crime resulting in patient death or major permanent loss of function.
• A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall.
• Hemolytic transfusion reaction involving major blood group incompatibilities.

Note: An adverse outcome that is directly related to the natural course of the patient's illness or underlying condition, e.g., terminal illness present at the time of presentation, is not reportable except for suicide in, or following elopement from, a 24-hour care setting (see preceding list).

Examples Of Events That Are Not Reportable To The Joint Commission

• Any "near miss."
• Full return of limb or bodily function to the same level as prior to the adverse event by discharge or within two weeks of the initial loss of said function.
• Any sentinel event that has not affected a recipient of care (patient, client, resident).
• Medication errors that do not result in death or major permanent loss of function.
• Suicide other than in an around-the-clock care setting or following elopement from such a setting.
• A death or loss of function following a discharge "against medical advice (AMA)."
• Unsuccessful suicide attempts.
• Unintentionally retained foreign body without major permanent loss of function.
• Minor degrees of hemolysis with no clinical sequelae.

Note: In the context of its performance improvement activities, an organization may choose to conduct intensive assessment, e.g., root cause analysis, for some non-reportable events. Please refer to the "Improving Organization Performance" chapter of your Joint Commission standards manual.