Proposed changes would toughen sentinel policy

Possible changes in the sentinel event policy would make it more strict in some regards but also eliminate some ambiguities that could result in an overuse of the accreditation watch status. The sentinel event program is administered by the Joint Commission on the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. The program allows the agency to place facilities on watch status after an egregious error that suggests a systemic problem threatening the health and safety of patients. (To help determine the root cause of an error, see chart inserted in this issue.)

The changes were proposed in an internal document. Linda Juhant, assistant director for hospitals and laboratories in the department of education programs, revealed the proposed changes to attendees of a recent risk management meeting, explaining that the changes had been proposed only days before. She says the proposal will be considered by Joint Commission officials but is uncertain how soon the changes could be implemented if approved.

These are the proposed changes:

1. The first criterion for establishing when an event is a sentinel event would be changed with an addition to clarify that the event was not a reasonable outcome. The criterion would be changed to say, "The event resulted in unanticipated death or major permanent loss of function not associated with the patient's primary condition."

2. Some events automatically would be considered sentinel events, regardless of the criteria otherwise used to make that determination. Those events would be infant abductions, discharging an infant to the wrong family, rape by a patient or staff member, a transfusion reaction because of mismatched blood, and surgery on the wrong patient or body part.

3. The Joint Commission may encourage self-reporting within five days of when you become aware of your sentinel event as a way to avoid being put on accreditation watch. If the event is reported within five days and an analysis is completed in 30 days and approved by the Joint Commission, the facility would not be placed on accreditation watch.