The Joint Commission Update for Infection Control

Joint Commission drops controversial IC patient safety goal on sentinel event reporting of HAIs

HAI deaths as sentinel events still required, but widely underreported

The Joint Commission has dropped a controversial infection prevention patient safety goal that recommended sentinel event investigations of unanticipated patient deaths and serious injuries due to health care-associated infections (HAIs). In doing so, however, The Joint Commission emphasized it was not discouraging such investigations, which indeed remain a requirement under existing sentinel event standards.

"It is already addressed through our sentinel event policies, so actually it was a redundant requirement," says Maureen Carr, project director of Standards and Survey Methods at The Joint Commission. "The reason for this revision was to really make sure that we were focusing on things that should be national patient safety goals. The feeling was that this was really covered under the sentinel event policy. We were already bringing attention to it there, and it wasn't needed as a national patient safety goal."

All accredited organizations must follow sentinel event policies, which call for root-cause analysis (RCA) of "events that result in unanticipated death or major, permanent loss of function not related to the natural course of illness," Carr says. "That would include [HAIs]."

As part of a renewed emphasis on infection prevention, the measure was first included in the 2004 patient safety goals and remained in effect through 2009. It was not continued in the 2010 patient safety goals. According to The Joint Commission, the RCA in such cases was to address "the management of the patient before and after the identification of infection."

The goal was plagued by underreporting, with The Joint Commission citing the apparent disconnect between the number of HAI deaths nationally and the paltry number of reports it was receiving. For example, The Joint Commission received some 15 sentinel event reports related to infection in 2007. Yet, according to the Centers for Disease Control and Prevention, 5%-10% of hospitalized patients develop an HAI, corresponding to approximately 2 million HAIs associated with nearly 100,000 deaths each year in U.S. hospitals.1

The "unanticipated" aspect of the definition may be part of the problem, as patients being kept alive by invasive devices may certainly have an HAI among their end-term sequela. In addition, reporting the RCA results was voluntary, but strongly encouraged to identify trends and improve patient safety. Resource and time constraints almost certainly inhibited reporting by hospitals and individual infection preventionists, but the bottom line is that unanticipated patient deaths or serious injuries due to HAIs still should be investigated as sentinel events.

"Absolutely, if you have somebody that dies, then we are normally doing a root-cause analysis on it anyway," emphasized Sue Dill Calloway, RN, MSN, JD, director of hospital patient safety at OHIC Insurance Co./The Doctors Co. in Columbus, OH. "Infection control is extremely important, but they thought [the requirement] was already reflected in the other standards. They still have a lot of infection control stuff in the [2010 patient safety goals] with central lines, surgical infections and multidrug-resistant organisms."

Indeed, against the backdrop of underreporting of sentinel events, the sweep of the 2010 goals raises the question of whether The Joint Commission is pushing infection prevention programs beyond their resources.

"Part of it is having a culture and leadership that is actually going to have the FTEs so the infection preventionist doesn't feel like they are drowning and they can't get the basics done," Calloway says. "The Joint Commission has eight pages of infection control standards and [they include requirements] that you have enough people and resources."

They do not require a specific staffing formula, however, and that may be part of the problem. The Joint commission "just says 'sufficient staffing' and that's pretty darn broad," she says.


  1. Yokoe DS, Classen D. Improving patient safety through infection control: A new health care imperative. Infect Control Hosp Epidemiol 2008; 29:S3-S11.