JCAHO sentinel events policy revamped again

For the third time this year, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in Oakbrook Terrace, IL, has changed its sentinel events policy. Adopted in September, the latest change extends from 30 to 45 days the time allowed an institution to submit a root cause analysis after a sentinel event occurs. The Joint Commission defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof."

In July, JCAHO began offering on-site review of written root cause analyses, and it has instituted provisions for "direct assessment of root cause analysis information without explicit review of the underlying document." Those changes respond to concerns about the possibility of outside liability based on root cause documents being submitted to the Joint Commission, as well as Accreditation Watch provisions that could allow parts of the documents to be made public.

Those changes follow more comprehensive ones that took effect in April. The earlier provisions made sentinel event reporting voluntary but added harsher penalties if an event occurs and is not reported. If an event is not reported and the Joint Commission learns of it elsewhere, the institution could face immediate Accreditation Watch status and potential public disclosure. But if self-reporting occurs within five days of an event, the institution is given 45 days to construct a root cause analysis and seek on-site review. Refusal to permit review of a response to a reported sentinel event can also result in Accreditation Watch status.

For more on the policy, contact JCAHO at (630) 916-5600. Also, see Drug Utilization Review, March 1998, for a policy overview and a pullout worksheet used by JCAHO as a sentinel events response document.