Hospitals are not required to report sentinel events to the Joint Commission (JC), but are encouraged to do so. However, many hospitals do not self-report. Whether or not hospitals report, each should have a facility policy in place addressing sentinel events. The Joint Commission reviews the activities of health care organizations in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys. The JC accreditation manual contains standards in the "Improving the Organization Performance" (PI) chapter relating specifically to managing sentinel events.

A sentinel event is defined as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." Serious injury specifically includes loss of limb or function, and risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The Joint Commission calls these events sentinel because they signal the need for immediate investigation and response. The terms sentinel event and medical error are not synonymous; not all sentinel events occur because of an error and not all errors results in sentinel events.

Hospital policy should be followed upon discovery of a sentinel event. The policy should clearly state whether or not the facility self-reports to the Joint Commission, and either way there should be a mechanism in place for the hospital's risk, quality, and legal departments to be notified. If the facility does not report, the Joint Commission can still discover sentinel events through complaints, the media, state and federal survey results, and discovery during Joint Commission surveys. The policy should also define the types of incidents that are considered reviewable under the sentinel event policy.

One of the goals of the Joint Commission's own Sentinel Event Policy is to have a positive impact on improving patient care, treatment, and services, and preventing sentinel events. The safety of patients should be the foundation on which all patient care activities are built upon. Preventing and reducing risk should be the goals of any patient safety program. To accomplish this, the organization that has experienced the event must focus on understanding the causes underlying the event, and changing its systems and processes to reduce the possibility of such an event in the future. The Joint Commission expects its accredited organizations to identify and respond appropriately to all sentinel events as defined by the organization, whether or not they self-report. This includes a timely, thorough, and credible root cause analysis, developing an action plan designed to implement improvements to reduce risk, implementing the improvements, and then monitoring the effectiveness of the improvements. A credible root cause analysis is a process for identifying the basic or causal factors that underlie variation in performance, including the occurrence or possible occurrence of a sentinel event. It focuses primarily on systems and processes, not individual performance. The Joint Commission provides a framework that can be utilized for conducting a credible root cause analysis.

Resources

The Joint Commission (2007). Sentinel Event Policies and Procedures. Updated July

Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved