JCAHO updates sentinel event policy - again

Fine-tuning eases some requirements

The sentinel event policy from the Joint Com mis sion on the Accreditation of Healthcare Organizations (JCAHO) is proving to be a squirmy beast, difficult to pin down and fully understand. But the JCAHO is slowly offering more and more explanations about how to interpret the policy, as well as some small changes that may make the policy less fearsome to risk managers.

The latest explanations from the JCAHO are supposed to clear up some of the more vexing questions about what must be reported and what the JCAHO does not expect to hear about. Other changes in the policy are intended to reduce the discoverability of information and the threats to patient confidentiality. In the latest meeting of the JCAHO board, the policy was changed to include one more event as automatically qualifying as a sentinel event - the suicide of a patient in a setting where the patient receives around-the-clock care, such as a hospital, a residential treatment center, or a crisis stabilization center.

That makes five situations that automatically qualify as sentinel events. The other four are an infant abduction or discharge to the wrong family, rape, a hemolytic transfusion reaction involving blood or blood products having major blood group incompatibilities, and surgery on the wrong patient or body part.

JCAHO provides examples

The JCAHO's sentinel event policy is voluntary, but risk managers have expressed confusion over what types of incidents (other than the five that qualify automatically) the JCAHO expects facilities to report as potential sentinel events. To ease the confusion, the JCAHO recently provided a list of examples it considers reportable and not reportable.

Here are the examples of incidents the JCAHO does consider reportable under the sentinel event policy:

· any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error;

· any elopement (an unauthorized departure) of a patient from an around-the-clock setting that results in a suicide, homicide, or major permanent loss of function;

· any maternal death related to the birth process;

· any perinatal death unrelated to a congenital condition in an infant having a birth weight greater than 2,500 g;

· assault, homicide, or other crime resulting in a 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.

The JCAHO specifies that "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 a suicide while in 24-hour care or following an elopement.

What you don't report

The commission also provides the following examples of incidents that should not be reported as potential sentinel events:

· any "near miss";

· an incident that results in full return of limb or bodily function to the same level as before the adverse event by discharge or within two weeks of the initial loss of function;

· any sentinel event that has not affected a recipient of care (a patient, client, or resident);

· medication errors that do not result in death or major permanent loss of function;

· a suicide that occurs in any setting other than around-the-clock care or following elopement from around-the-clock care;

· a death or loss function following a discharge against medical advice;

· unsuccessful suicide attempts;

· an unintentionally retained foreign body without major permanent loss of function;

· minor degrees of hemolysis with no clinical sequelae.

The JCAHO offers these explanations of a few finer points: The determination of what constitutes rape should be based on the health care organization's definition, consistent with the applicable laws. Providers are not expected to report rape allegations to the JCAHO, and actual rapes need not be reported to the JCAHO if such reporting is prohibited by law. The five-day time frame for voluntarily reporting begins when you make a determination that a rape did occur, not when the allegation is made.

Also, all events of surgery on the wrong patient or body part are reportable. It does not matter how minor the provider considers the event to be.

Send inspector, not documents

Another policy change addresses the con cern that the JCAHO's required root cause analysis after a sentinel event would waive the legal protection usually afforded much of the information therein. To get around that, the Joint Commission authorized on-site review of the root-cause analysis or on-site interviews with a review of relevant documentation to verify that there was an appropriate analysis of the event. The on-site reviews will be conducted by specially trained JCAHO surveyors beginning July 1, 1998, at a cost of $2,300 for a one-day visit.

The JCAHO states that the on-site visits are only an interim measure until legal protection is afforded the root cause analysis; the commission still prefers to receive the written report as the policy originally required.

Also, the JCAHO modified the policy to allow an organization that has not voluntarily self-reported an event 30 days to complete a root cause analysis without the risk of being placed on accredi tation watch. That means the time frame for completing a root cause analysis is the same whether self-reporting occurs or not.

[Editor's note: To speak with a JCAHO representative, request a sentinel event reporting form, or check the status of a report, call the JCAHO's sentinel event hotline at (630) 792-3700.]