Do you have to tell The Joint Commission?

Requirements spelled out for patient deaths

When a patient death occurs in outpatient surgery, you do have a choice about whether you report the occurrence to The Joint Commission.

"In light of improving quality and patient safety, it's a nonpunitive action," says Virginia McCollum, RN, MSN, associate director of standards interpretation at The Joint Commission. When administrators decide to report a death or other sentinel event, they are not jeopardizing their accreditation "or getting in trouble," she says.

Sentinel events are handled confidentially, and the information is not shared with surveyors, says Anita Giuntoli, RN, MJ, BSN, associate director of the Office of Quality Monitoring at The Joint Commission. However, surveyors do determine whether all facilities have conducted root-cause analyses of any adverse events, McCollum says.

If a surveyor determines during the survey process that a sentinel event occurred with 12 months of the survey, the surveyor will inform the CEO and communicate that event to The Joint Commission central office. "If, in any way, shape, or form, we find out about a sentinel event, it's incumbent on us to explore with the organization and make sure they have taken appropriate follow-up steps," Giuntoli says.

When a facility reports a sentinel event to The Joint Commission, there are master's-prepared nurses who are experts in root-cause analyses who offer their help, she says. "We make sure the root-cause analysis is thorough and credible."

Once the analysis is complete, the organization is required to create a plan of action to address all the root causes, Giuntoli says. The organization must develop a measure to see if the plan is working, she says. For example, if the facility had a wrong-site surgery and failed to implement a timeout prior to surgery, one of the plans of action might be to perform a timeout in the future, designate who would lead the timeout, and who would document it. The organization would conduct 100% measurement of the frequency of timeout to determine the measure of success (MOS). "If it's not successful, we'll work with them until it is," Giuntoli says.

The expectation is that there will be a quality improvement process, McCollum says. "We expect that they will take any adverse event — death or wrong site surgery or whatever the event is — collect, aggregate, and analyze data; and make changes based on the data," she says. "It's probably the most important thing you can do."


For information on how accredited facilities should address a sentinel event such as a death, go to Under "Sentinel Events," click on "Policy and Procedures."