JCAHO modifies sentinel event policy

As predicted in the January 1998 Healthcare Risk Management, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, has revised its "sentinel event" policy to provide more confidentiality and offer rewards for providers who report their own incidents. But don’t let your guard down — there’s still plenty of bite left in that dog.

JCAHO previously has defined a sentinel event as "any unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof." With the new changes, that definition includes specific incidents without the need for interpretation. JCAHO now says these incidents automatically are classified as sentinel events:

• infant abduction;

• infant discharged to the wrong family;

• rape by a patient or staff member;

• transfusion reaction from mismatched blood;

• surgery on the wrong patient or body part.

Further, JCAHO states that "serious" injuries include loss of a limb or limb function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. However, the sentinel event policy is invoked only if the sentinel event actually results in an unanticipated death or major permanent loss of function.

JCAHO also is offering a reward for providers who report their own events instead of waiting to see if the commission hears about them. Under the new provision, a provider who reports a sentinel event within five business days of the occurrence (or five days of when the provider becomes aware of it) will not be placed on accreditation watch status. Also, the provider usually will not be subject to an immediate on-site review. Instead, the provider will be given 30 more days to complete a root cause analysis, submit it to JCAHO, and implement appropriate improvements. JCAHO then will follow up within six months.

The new policy offers more confidentiality to the provider. Previously, the provider’s sentinel event would be disclosed as a matter of public record when the Joint Commission put the organization on accreditation watch status. Under the new confidentiality provision, that changes. If the JCAHO were to receive an inquiry about the accreditation status of an organization during the 30-day root cause analysis period, the accreditation status would be reported in the usual manner without any reference to the sentinel event.

There is an important caveat: If the inquirer refers specifically to the sentinel event, the Joint Commission will acknowledge it is working with the provider through its sentinel event process.

Self-reporting of sentinel events still is voluntary. JCAHO now stresses, though, that a provider who does not self-report is at risk of being placed on accreditation watch status once the event becomes known, implying the provider’s failure to step forward may be punished with a higher likelihood of accreditation watch. And an organization that fails to perform and submit an appropriate root cause analysis within 30 days waives the new limited confidentiality protection. (JCAHO still won’t disclose the contents of the root cause analysis, though it may be available through other agencies working with the commission.)

Waiving your limited confidentiality protections also can be costly in a direct way: It makes you subject to immediate and/or follow-up site evaluations, each at a cost of $3,500.