Joint Commission Online - Aug. 12, 2020
Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday.
August 12, 2020
Through the first six months of 2020, The Joint Commission reviewed a total of 437 sentinel events. The majority — 372 or 85% — were voluntarily self-reported by an accredited or certified organization.
In accordance with the Sentinel Event Policy, and as required by Leadership (LD) Standard LD.03.09.01, accredited organizations must review all sentinel events and implement risk reduction strategies to prevent recurrence.
Less than an estimated 2% of all sentinel events are reported to The Joint Commission. Of these, 60% (9,422 of 15,770 events) have been self-reported since 2005. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. The most frequently reported types of sentinel events reported from Jan. 1 through June 30 were from the following categories:
- Care management
- Surgical or invasive procedures
- Unassigned events at the time of the report
- Protection events
- Environment events
- Product or device
While COVID-19 has presented significant challenges for all health care organizations, the number of sentinel events remained comparable to 2019.
“As COVID-19 uniquely challenged our accredited health care organizations, future studies will be required to fully quantify its true impact as a causative factor in sentinel events,” stated Raji Thomas, DNP, MBA, CPHQ, CPPS, director of the Office of Quality and Patient Safety, The Joint Commission.
The patient safety specialists in the Joint Commission’s Office of Quality and Patient Safety work with organizations reporting sentinel events to identify contributing factors and actions the organization can take to reduce risk.
“Our patient safety specialists have been sensitive to the unprecedented stressors that health care organizations face because of the pandemic,” Thomas stated. “Our department strives to be nimble and accommodating to meet the individualized needs of organizations as they manage competing priorities. We appreciate that health care organizations continue to find value in working with The Joint Commission to evaluate harm events and implement sustainable mitigation plans to prevent recurrences while managing these unfamiliar crisis situations.”
Learn more about sentinel events or call the Office of Quality and Patient Safety at 630-792-3700.
August 12, 2020
Joint Commission staff are on the front lines of COVID-19 care, and we’re sharing their experiences in ‘Real Voices. Real Stories.’
A surveyor for The Joint Commission, Emalyn Bravo, RN, shared the nontraditional solutions her medical community is using to deal with the issues the COVID-19 pandemic has presented.
“We have worked hard to keep our residents engaged with various activities due to visiting restrictions,” she said. “To keep families informed, we provide regular updates and offer a hotline for questions. FaceTime has been an integral tool to help families talk to their loved ones. We also use it to include families in our regular interdisciplinary team meetings.”
“As we take care of the residents and their families, we have not lost sight in taking care of our own ‘local heroes’, the front liners in the facility. We make sure to provide emotional and psychological support resources and have a meditation room that they can use 24/7 to release their work stresses. During this critical and most difficult time, I salute all the front liners out there who are risking their lives to save lives.”
Read ‘Real Voices. Real Stories.’
August 12, 2020
Ambulatory Buzz — COVID-19 Related Environment of Care & Air Exchanges FAQs: Over the past few months, while dealing with this pandemic, many of our ambulatory care colleagues have reached out to The Joint Commission with COVID-19 related environment of care and air exchanges questions, writes James Kendig, MS, CHSP, CHCM, CHEM, LHRM, field director, surveyor management and development, Accreditation and Certification Operations.