Sentinel Events In support of its mission to continuously improve the safety and quality of health care provided to the public The Joint Commission in its accreditation process reviews hospitals activities in response t ID: 12423
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SentinelEvents(SE) I.SentinelEvents Insupportofitsmissiontocontinuouslyimprovethesafetyandqualityofhealthcare providedtothepublic,TheJointCommissioninitsaccreditationprocessreviews hospitalsactivitiesinresponsetosentinelevents.Theaccreditationprocessincludesall fullaccreditationsurveysand,asappropriate,for-causesurveys,andrandomvalidation surveysspecifictoEvidenceofStandardsCompliance(ESC). QAsentineleventisanunexpectedoccurrenceinvolvingdeathorseriousphysicalor psychologicalinjury,ortheriskthereof.Seriousinjuryspecificallyincludeslossof limborfunction.Thephraseortheriskthereofincludesanyprocessvariationfor whicharecurrencewouldcarryasignificantchanceofaseriousadverseoutcome. QSucheventsarecalledsentinelbecausetheysignaltheneedforimmediate investigationandresponse. QThetermssentineleventanderrorarenotsynonymous;notallsentinelevents occurbecauseofanerror,andnotallerrorsresultinsentinelevents. II.GoalsoftheSentinelEventPolicy Thepolicyhasfourgoals: 1.Tohaveapositiveimpactinimprovingpatientcare,treatment,andservicesand preventingsentinelevents 2.Tofocustheattentionofahospitalthathasexperiencedasentineleventon understandingthefactorsthatcontributedtotheevent(suchasunderlyingcauses, latentconditionsandactivefailuresindefensesystems,ororganizationalculture), andonchangingthehospitalsculture,systems,andprocessestoreducethe probabilityofsuchaneventinthefuture 3.Toincreasethegeneralknowledgeaboutsentinelevents,theircontributingfactors, andstrategiesforprevention 4.Tomaintaintheconfidenceofthepublicandaccreditedhospitalsinthe accreditationprocess CAMH,January2013 SE1 ÕComprehensiveAccreditationManualforHospitals III.StandardsRelatingtoSentinelEvents Standards EachJointCommissionaccreditationmanualcontainsstandardsintheLeadership (LD)chapterthatrelatespecificallytothemanagementofsentinelevents. Hospital-SpecificDefinitionofSentinelEvent LD.04.04.05,EP7,requireseachaccreditedhospitaltodefinesentineleventforitsown purposesandtocommunicatethisdefinitionthroughouttheorganization.Whilethis definitionmustbeconsistentwiththegeneraldefinitionofsentineleventaspublishedby TheJointCommission,accreditedhospitalshavesomelatitudeinsettingmorespecific parameterstodefineunexpected,serious,andtheriskthereof.Ataminimum,ahospitals definitionmustincludethoseapplicableeventsthataresubjecttoreviewunderthe SentinelEventPolicyasdefinedinSectionIVofthischapter. ExpectationsUndertheStandardsfora HospitalsResponsetoaSentinelEvent Accreditedhospitalsareexpectedtoidentifyandrespondappropriatelytoallsentinel events(asdefinedbythehospitalinaccordancewiththeprecedingparagraph)occurring inthehospitalorassociatedwithservicesthatthehospitalprovides,orprovidesfor. Appropriateresponseincludesconductingatimely,thorough,andcrediblerootcause analysis;developinganactionplandesignedtoimplementimprovementstoreducerisk; implementingtheimprovements;andmonitoringtheeffectivenessofthoseimprove- ments. RootCauseAnalysis Rootcauseanalysisisaprocessforidentifyingthefactorsthatunderlievariationin performance,includingtheoccurrenceorpossibleoccurrenceofasentinelevent.Aroot causeanalysisfocusesprimarilyonsystemsandprocesses,notonindividualperform- ance.Theanalysisprogressesfromspecialcauses*inclinicalprocessestocommon *Specialcauseisafactorthatintermittentlyandunpredictablyinducesvariationoverandabovewhatis inherentinthesystem.Itoftenappearsasanextremepoint(suchasapointbeyondthecontrollimits onacontrolchart)orsomespecific,identifiablepatternindata. SE2 CAMH,January2013 SentinelEventsÖ causesinorganizationalprocessesandsystemsandidentifiespotentialimprovementsin theseprocessesorsystemsthatwouldtendtodecreasethelikelihoodofsucheventsin thefutureordetermines,afteranalysis,thatnosuchimprovementopportunitiesexist. ActionPlan Theproductoftherootcauseanalysisisanactionplanthatidentifiesthestrategiesthat thehospitalintendstoimplementinordertoreducetheriskofsimilareventsoccurring inthefuture.Theplanshouldaddressresponsibilityforimplementation,oversight,pilot testingasappropriate,timelines,andstrategiesformeasuringtheeffectivenessofthe actions. SurveyProcess Whenconductinganaccreditationsurvey,TheJointCommissionseekstoevaluatethe hospitalscompliancewiththeapplicablestandards,NationalPatientSafetyGoals,and AccreditationParticipationRequirements,andtoscorethoserequirementsbasedon performancethroughoutthehospitalovertime.Surveyorsareinstructednottosearch forsentineleventsduringausualsurveyortoinquireaboutsentineleventsthathave beenreportedtoTheJointCommission.Surveyorsmayconductanassessmentofa hospitalsperformanceimprovementpracticesandprocedures,suchasrootcause analysesandproactiveriskassessment. If,inthecourseofconductingtheusualsurveyactivities,asentineleventis(newly) identified,thesurveyorwilltakethefollowingsteps: QInformtheCEOthattheeventhasbeenidentified QInformtheCEOtheeventwillbereportedtoTheJointCommissionforfurther reviewandfollow-upundertheprovisionsoftheSentinelEventPolicy.The surveyormakesnodeterminationofwhetherornottheeventisareviewable sentinelevent,butratherwillhandofffurtherdiscussiontoJointCommission CentralOfficestaffintheSentinelEventUnitoftheOfficeofQualityMonitoring. StaffintheSentinelEventUnitwillcontactthehospitalafterallsurveyactivityis entirelycompletedtoexploretheeventanddeterminewhetherornotsubmissionof Commoncauseisafactorthatresultsfromvariationinherentintheprocessorsystem.Theriskofa commoncausecanbereducedbyredesigningtheprocessorsystem. CAMH,January2013 SE3 ÕComprehensiveAccreditationManualforHospitals arootcauseanalysisisrequired.Ifso,thehospitalwillproceedwiththesteps describedafteraneventisdeterminedtobereviewable.(SeetheRequiredResponse toaReviewableSentinelEventsectioninthischapter.) Duringtheon-sitesurvey,thesurveyor(s)willassessthehospitalscompliancewith sentineleventrelatedstandardsinthefollowingways: QReviewthehospitalsprocessforrespondingtoasentinelevent QInterviewthehospitalsleadersandstaffabouttheirexpectationsandresponsibilities foridentifying,reportingon,andrespondingtosentinelevents QAskforanexampleofarootcauseanalysisthathasbeenconductedoutsidethe mostrecent12-monthperiodtoassesstheadequacyofthehospitalsprocessfor respondingtoasentinelevent.Additionalexamplesmaybereviewedifneededto morefullyassessthehospitalsunderstandingofandabilitytoconductrootcause analyses.Inselectinganexample,thehospitalmaychooseaclosedcaseoranear misstodemonstrateitsprocessforrespondingtoasentinelevent. IV.ReviewableSentinelEvents DefinitionofOccurrencesThatAreSubjectto ReviewbyTheJointCommissionUnderthe SentinelEventPolicy Thedefinitionofareviewablesentineleventtakesintoaccountawidearrayof occurrencesapplicabletoawidevarietyofhealthcareorganizations.Anyorall occurrencesmayapplytoaparticulartypeofhospital.Thus,notallofthefollowing occurrencesmayapplytoyourparticularhospital.Thesubsetofsentineleventsthatis subjecttoreviewbyTheJointCommissionincludesanyoccurrencethatmeetsanyof thefollowingcriteria: NearmissorclosecallUsedtodescribeanyprocessvariationthatdidnotaffectanoutcomebutfor whicharecurrencecarriesasignificantchanceofaseriousadverseoutcome.Sucheventsfallwithinthe scopeofthedefinitionofasentineleventbutoutsidethescopeofthosesentineleventsthataresubject toreviewbyTheJointCommissionunderitsSentinelEventPolicy. SE4 CAMH,January2013 SentinelEventsÖ QTheeventhasresultedinanunanticipateddeathormajorpermanentlossof functionnotrelatedtothenaturalcourseofthepatientsillnessorunderlying condition§|| or QTheeventisoneofthefollowing(eveniftheoutcomewasnotdeathormajor permanentlossoffunctionnotrelatedtothenaturalcourseofthepatientsillness orunderlyingcondition): RSuicideofanypatientreceivingcare,treatmentandservicesinastaffedaround- the-clockcaresettingorwithin72hoursofdischarge RUnanticipateddeathofafull-terminfant RAbductionofanypatientreceivingcare,treatment,andservices RDischargeofaninfanttothewrongfamily RRape,assault(leadingtodeathorpermanentlossoffunction),orhomicideof anypatientreceivingcare,treatment,andservices# RRape,assault(leadingtodeathorpermanentlossoffunction),orhomicideofa staffmember,licensedindependentpractitioner,visitor,orvendorwhileonsite atthehealthcareorganization §Adistinctionismadebetweenanadverseoutcomethatisprimarilyrelatedtothenaturalcourseofthe patientsillnessorunderlyingcondition(notreviewedundertheSentinelEventPolicy)andadeathor majorpermanentlossoffunctionthatisassociatedwiththetreatment(includingrecognized complications)orlackoftreatmentofthatcondition,orotherwisenotclearlyandprimarilyrelatedto thenaturalcourseofthepatientsillnessorunderlyingcondition(reviewableundertheSentinelEvent Policy).Inindeterminatecases,theeventwillbepresumedreviewableandthehospitalsresponsewill bereviewedundertheSentinelEventPolicyaccordingtotheprescribedproceduresandtimeframes withoutdelayforadditionalinformationsuchasautopsyresults. ||Majorpermanentlossoffunctionmeanssensory,motor,physiologic,orintellectualimpairmentnot presentonadmissionrequiringcontinuedtreatmentorlifestylechange.Whenmajorpermanentlossof functioncannotbeimmediatelydetermined,applicabilityofthepolicyisnotestablisheduntileither thepatientisdischargedwithcontinuedmajorlossoffunctionortwoweekshaveelapsedwith persistentmajorlossoffunction,whicheveristhelongerperiod. #Sexualabuse/assault(includingrape),asareviewablesentinelevent,isdefinedasunconsentedsexual contactinvolvingapatientandanotherpatient,staffmember,orotherperpetratorwhilebeingtreated oronthepremisesofthehospital,includingoral,vaginaloranalpenetrationorfondlingofthe patientssexorgan(s)byanotherindividualshand,sexorgan,orobject.Oneormoreofthefollowing mustbepresenttodeterminereviewability: QAnystaff-witnessedsexualcontactasdescribedabove QAdmissionbytheperpetratorthatsexualcontact,asdescribedabove,occurredonthepremises QSufficientclinicalevidenceobtainedbythehospitaltosupportallegationsofunconsentedsexual contact ShadingindicatesachangeeffectiveJuly1,2013,unlessotherwisenotedintheTableofChanges. CAMHUpdate1,March2013 SE5 ÕComprehensiveAccreditationManualforHospitals RHemolytictransfusionreactioninvolvingadministrationofbloodorblood productshavingmajorbloodgroupincompatibilities(ABO,Rh,otherblood groups) RInvasiveprocedure,includingsurgery,onthewrongpatient,wrongsite,or wrongprocedure** RUnintendedretentionofaforeignobjectinapatientaftersurgeryorother invasiveprocedures RSevereneonatalhyperbilirubinemia(bilirubin30milligrams/deciliter) RProlongedfluoroscopywithcumulativedose1,500radstoasinglefieldorany deliveryofradiotherapytothewrongbodyregionor25%abovetheplanned radiotherapydose ExamplesofreviewablesentineleventsareprovidedinTable1(pageSE-7).Examplesof sentineleventsthatareoutsidethescopeofthosesentineleventsthataresubjectto reviewbyTheJointCommissionundertheSentinelEventPolicyareprovidedinTable 2(pageSE-8). **Alleventsofinvasiveprocedure,includingsurgery,onthewrongpatient,wrongsite,orwrong procedurearereviewableunderthepolicy,regardlessofthemagnitudeoftheprocedureorthe outcome. ShadingindicatesachangeeffectiveJuly1,2013,unlessotherwisenotedintheTableofChanges. SE6 CAMHUpdate1,March2013 SentinelEventsÖ Table1.ExamplesofSentinelEventsThatAre ReviewableUnderTheJointCommissionsSentinel EventPolicy Note:Thislistmaynotapplytoallsettings. Examplesincludethefollowing: Anypatientdeath,paralysis,coma,orothermajorpermanentlossof functionassociatedwithamedicationerror Apatientcommitssuicidewithin72hoursofbeingdischargedfroma hospitalsettingthatprovidesstaffedaround-the-clockcare Anyelopement,thatis,unauthorizeddeparture,ofapatientfromanaround- the-clockcaresettingresultinginatemporallyrelateddeath(suicide, accidentaldeath,orhomicide)ormajorpermanentlossoffunction Ahospitalperformingthewronginvasiveprocedureoroperatingonthe wrongsideofthepatientsbody,onthewrongsiteonthepatientsbody,or onthewrongpatient Anyintrapartum(relatedtothebirthprocess)maternaldeath Anyperinataldeathunrelatedtoacongenitalconditioninaninfanthavinga birthweightgreaterthan2,500grams Apatientisabductedfromthehospitalwhereheorshereceivescare, treatment,orservices Assault,homicide,orothercrimeresultinginpatientdeathormajor permanentlossoffunction Assault,homicide,orothercrimeresultingindeathormajorpermanentloss offunctionofastaffmember,licensedindependentpractitioner,visitor,or vendor Apatientfallthatresultsindeathormajorpermanentlossoffunctionasa directresultoftheinjuriessustainedinthefall Hemolytictransfusionreactioninvolvingmajorbloodgroupincompatibilities Aforeignbody,suchasaspongeorforceps,thatwasleftinapatientafter surgery Note:Anadverseoutcomethatisdirectlyrelatedtothenaturalcourseofthe patientsillnessorunderlyingcondition,forexample,terminalillnesspresent atthetimeofpresentation,isnotreportableexceptforsuicidein,orfollowing elopementfrom,a24-hourcaresetting(seeabove). ShadingindicatesachangeeffectiveJuly1,2013,unlessotherwisenotedintheTableofChanges. CAMHUpdate1,March2013 SE7 ÕComprehensiveAccreditationManualforHospitals Table2.ExamplesofSentinelEventsThatAreNot ReviewableUnderTheJointCommissionsSentinel EventPolicy Note:Thislistmaynotapplytoallsettings. Examplesincludethefollowing: Anyclosecall(nearmiss) Fullorexpectedreturnoflimborbodilyfunctiontothesamelevelaspriorto theadverseeventbydischargeorwithintwoweeksoftheinitiallossofsaid function,whicheveristhelongerperiod Anysentineleventthathasnotaffectedarecipientofcare(patient, individual,resident) Medicationerrorsthatdonotresultindeathormajorpermanentlossof function Suicideotherthaninanaround-the-clockcaresettingorfollowingelopement fromsuchasetting Adeathorlossoffunctionfollowingadischargeagainstmedicaladvice (AMA) Unsuccessfulsuicideattemptsunlessresultinginmajorpermanentlossof function Minordegreesofhemolysisnotcausedbyamajorbloodgroupincompati- bilityandwithnoclinicalsequelae Note:Inthecontextofitsperformanceimprovementactivities,ahospitalmay choosetoconductintensiveassessment,forexample,rootcauseanalysis, forsomenotreviewableevents.PleaserefertothePerformanceImprove- ment(PI)chapterofthisaccreditationmanual. HowTheJointCommissionBecomesAwareof aSentinelEvent Eachhospitalisencouraged,butnotrequired,toreporttoTheJointCommissionany sentineleventmeetingthecriteriaforreviewablesentinelevents.Alternatively,TheJoint Commissionmaybecomeawareofasentineleventbysomeothermeanssuchas communicationfromapatient,afamilymember,anemployeeofthehospital,ora surveyor,orthroughthemedia. ShadingindicatesachangeeffectiveJuly1,2013,unlessotherwisenotedintheTableofChanges. SE8 CAMHUpdate1,March2013 SentinelEventsÖ ReasonsforReportingaSentinelEventtoThe JointCommission Althoughself-reportingasentineleventisnotrequiredandthereisnodifferenceinthe expectedresponse,timeframes,orreviewprocedures,whetherthehospitalvoluntarily reportstheeventorTheJointCommissionbecomesawareoftheeventbysomeother means,thereareseveraladvantagestothehospitalthatself-reportsasentinelevent: QReportingtheeventenablestheadditionofthelessonslearnedfromtheeventto beaddedtoTheJointCommissionsSentinelEventDatabase,therebycontributing tothegeneralknowledgeaboutsentineleventsandtothereductionofriskforsuch eventsinmanyotherhospitals. QEarlyreportingprovidesanopportunityforconsultationwithJointCommission staffduringthedevelopmentoftherootcauseanalysisandactionplan. QThehospitalsmessagetothepublicthatitisdoingeverythingpossibletoensure thatsuchaneventwillnothappenagainisstrengthenedbyitsacknowledged collaborationwithTheJointCommissiontounderstandhowtheeventhappened andwhatcanbedonetoreducetheriskofsuchaneventinthefuture. RequiredResponsetoaReviewableSentinel Event IfTheJointCommissionbecomesaware(eitherthroughvoluntaryself-reportingor otherwise)ofasentineleventthatmeetsthecriteriaofthispolicyandtheeventhas occurredinanaccreditedhospital,thehospitalisexpectedtodothefollowing: QPrepareathoroughandcrediblerootcauseanalysisandactionplanwithin45 calendardaysoftheeventorofbecomingawareoftheevent QSubmittoTheJointCommissionitsrootcauseanalysisandactionplan,or otherwiseprovideforJointCommissionevaluationofitsresponsetothesentinel eventunderanapprovedprotocol(seeSectionVI),within45calendardaysofthe knownoccurrenceoftheevent TheJointCommissionwillthendeterminewhethertherootcauseanalysisandaction planareacceptable.IfthedeterminationthataneventisreviewableundertheSentinel EventPolicyoccursmorethan45calendardaysfollowingtheknownoccurrenceofthe event,thehospitalsresponsewillbeduein15calendardays.Ifthehospitalhasfailedto submitarootcauseanalysiswithinanadditional45daysfollowingitsduedate,its accreditationdecisionmaybeimpacted. CAMH,January2013 SE9 ÕComprehensiveAccreditationManualforHospitals Pleasenotethatahospitalthatexperiencesasentineleventasdefinedbythehospital, butthatdoesnotmeetthecriteriaforreviewundertheSentinelEventPolicy,isstill expectedtocompletearootcauseanalysis(asrequiredbyStandardLD.04.04.05)but doesnotneedtosubmitittoTheJointCommission. ReviewofRootCauseAnalysesandAction Plans Arootcauseanalysiswillbeconsideredacceptableacceptableifithasthefollowingcharacteristics: QTheanalysisfocusesprimarilyonsystemsandprocesses,notonindividual performance QTheanalysisprogressesfromspecialcausesinclinicalprocessestocommoncausesin organizationalprocesses QTheanalysisrepeatedlydigsdeeperbyaskingWhy?;then,whenanswered, Why?again,andsoon QTheanalysisidentifieschangesthatcouldbemadeinsystemsandprocesses(either throughredesignordevelopmentofnewsystemsorprocesses)thatwouldreduce theriskofsucheventsoccurringinthefuture QTheanalysisisthoroughandcredible Tobethoroughthorough,therootcauseanalysismustincludethefollowing: QAdeterminationofthehumanandotherfactorsmostdirectlyassociatedwiththe sentineleventandtheprocess(es)andsystemsrelatedtoitsoccurrence QAnanalysisoftheunderlyingsystemsandprocessesthroughaseriesofWhy? questionstodeterminewhereredesignmightreducerisk QAninquiryintoallareasappropriatetothespecifictypeofeventasdescribedin Table3(pageSE-11) QAnidentificationofriskpointsandtheirpotentialcontributionstothistypeof event QAdeterminationofpotentialimprovementinprocessesorsystemsthatwouldtend todecreasethelikelihoodofsucheventsinthefuture,oradetermination,after analysis,thatnosuchimprovementopportunitiesexist Tobecrediblecredible,therootcauseanalysismustdothefollowing: QIncludeparticipationbytheleadershipofthehospitalandbyindividualsmost closelyinvolvedintheprocessesandsystemsunderreview QBeinternallyconsistent(thatis,notcontradictitselforleaveobviousquestions unanswered) SE10 CAMH,January2013 SentinelEventsÖ QProvideanexplanationforallfindingsofnotapplicableornoproblem QIncludeconsiderationofanyrelevantliterature Anactionplanwillbeconsideredacceptableifitdoesthefollowing: QIdentifieschangesthatcanbeimplementedtoreduceriskorformulatesarationale fornotundertakingsuchchanges QIdentifies,insituationswhereimprovementactionsareplanned,whoisresponsible forimplementation,whentheactionwillbeimplemented(includinganypilot testing),andhowtheeffectivenessoftheactionswillbeevaluated Allrootcauseanalysesandactionplanswillbeconsideredandtreatedasconfidentialby TheJointCommission.Adetailedlistingoftheminimumscopeofrootcauseanalysis forspecifictypesofsentineleventsisincludedinTable3(below). Table3.MinimumScopeofRootCauseAnalysisfor SpecificTypesofSentinelEvents Detailedinquiryintotheseareasisexpectedwhenconductingarootcause analysisforthespecifiedtypeofsentinelevent.Inquiryintoareasnotchecked (orlisted)shouldbeconductedasappropriatetothespecificeventunderreview. TYPESOFSENTINELEVENTS AreasofPotentialRootCauses Suicide(24-HourCare) MedicationError ProceduralComplication Wrong-SiteSurgery TreatmentDelay RestraintDeath ElopementDeath Assault/Rape/Homicide TransfusionReaction PatientAbduction UnanticipatedDeathof Full-TermInfant UnintendedRetentionof ForeignBody FallRelated X X X X Behavioralassessmentprocess X X X X X X X X X Physicalassessmentprocess Individualidentificationprocess X X X Individualobservationprocedures X X X X X X X X Careplanningprocess X X X X X X Continuumofcare X X X X X Staffinglevels X X X X X X X X X X X X Orientationandtrainingofstaff X X X X X X X X X X X X X continuedonnextpage Includestheprocessforassessingindividualsrisktoself(andtoothers,incasesofassault,rape,or homicidewhereanindividualistheassailant). Includessearchforcontraband. CAMH,January2013 SE11 ÕComprehensiveAccreditationManualforHospitals Table3.(continued) CAMH,January2013 TYPESOFSENTINELEVENTS AreasofPotentialRootCauses Suicide(24-HourCare) MedicationError ProceduralComplication Wrong-SiteSurgery TreatmentDelay RestraintDeath ElopementDeath Assault/Rape/Homicide TransfusionReaction PatientAbduction UnanticipatedDeathof Full-TermInfant UnintendedRetentionof ForeignBody FallRelated Competencyassessment/credentialing X X X X X X X X X X X X X X X X X X X X Supervisionofstaff§§ Communicationwithindividual/family X X X X X X X X Communicationamongstaffmembers X X X X X X X X X X X X X Availabilityofinformation X X X X X X X X X Adequacyoftechnologicalsupport X X Equipmentmaintenance/management X X X X X X X X X X X X X X X X Physicalenvironment|||| Securitysystemsandprocesses X X X X X X X X X X X Medicationmanagement## Follow-upActivities AftertheJointCommissionhasdeterminedthatahospitalhasconductedanacceptable rootcauseanalysisanddevelopedanacceptableactionplan,TheJointCommissionwill notifyitthattherootcauseanalysisandactionplanareacceptableandwillassignan appropriatefollow-upactivity,typicallyoneormoreSentinelEventMeasuresofSuccess (SEMOS)dueinfourmonths.(SeetheSentinelEventMeasuresofSuccesssectionfor moredetails.) §§Includessupervisionofphysicians-in-training. ||||Includesfurnishings;hardware(forexample,bars,hooks,rods);lighting;distractions. ##Includesselectionandprocurement;storage;orderingandtranscribing;preparinganddispensing; administration;andmonitoring. SE12 SentinelEventsÖ V.TheSentinelEventDatabase ToachievethethirdgoaloftheSentinelEventPolicy,toincreasethegeneral knowledgeaboutsentinelevents,theircontributingfactors,andstrategiesforpreven- tion,TheJointCommissioncollectsandanalyzesdatafromthereviewofsentinel events,rootcauseanalyses,actionplans,andfollow-upactivities.Thesedataand informationformthecontentoftheJointCommissionsSentinelEventDatabase. TheJointCommissioniscommittedtodevelopingandmaintainingthisSentinelEvent Databaseinafashionthatwillprotecttheconfidentialityofthehospital,thecaregiver, andthepatient.Includedinthisdatabasearethreemajorcategoriesofdataelements: 1.Sentineleventdata 2.Rootcausedata 3.Riskreductiondata De-identifiedaggregatedatarelatingtorootcausesandrisk-reductionstrategiesfor sentineleventsthatoccurwithsignificantfrequencywillformthebasisforfutureerror- preventionadvicetohospitalsthroughSentinelEventAlertandothermedia.The SentinelEventDatabaseisalsoamajorcomponentoftheevidencebasefordeveloping andmaintainingtheNationalPatientSafetyGoals. VI.ProceduresforImplementingthe SentinelEventPolicy VoluntarySelfReportingofReviewable SentinelEventstotheJointCommission Ifahospitalwishestoreportanoccurrenceinthesubsetofsentineleventsthatare subjecttoreviewbyTheJointCommission,thehospitalwillbeaskedtocompletea formaccessiblethroughitsJointCommissionConnectextranetsite.Fromthissite,select SelfReportSentinelEventfromtheContinuousComplianceToolssection. ReviewableSentinelEventsThatAreNot ReportedbytheHospital IfTheJointCommissionbecomesawareofasentineleventsubjecttoreviewunderthe SentinelEventPolicywhichwasnotreportedtoTheJointCommissionbythehospital, theCEOordesigneeofthehospitaliscontacted,andapreliminaryassessmentofthe CAMH,January2013 SE13 ÕComprehensiveAccreditationManualforHospitals sentineleventismade.AneventthatoccurredmorethanoneyearbeforethedateThe JointCommissionbecameawareoftheeventwillnot,inmostcases,bereviewedunder theSentinelEventPolicy.Insuchacase,awrittenresponsewillberequestedfromthe hospital,includingasummaryofprocessesinplacetopreventsimilaroccurrences. DeterminationThataSentinelEventIs ReviewableUndertheSentinelEventPolicy Basedonavailablefactualinformationreceivedabouttheevent,JointCommissionstaff willdeterminewhethertheeventisreviewableundertheSentinelEventPolicy.(Seethe ReviewableSentinelEventssectionformoredetails.)Challengestoadeterminationthat aneventisreviewablewillberesolvedthroughconsultationwithseniorJoint Commissionstaff. InitialOn-SiteReviewofaSentinelEvent Aninitialon-sitereviewofasentineleventwillusuallynotbeconductedunlessitis determinedthatthereisapotentialongoingimmediatethreattopatienthealthorsafety orpotentiallysignificantnoncompliancewithJointCommissionstandards.Immediate ThreattoHealthorSafetyincidentsincludesituationsinwhichthehospitals noncompliancewithoneormorestandardshascaused,orislikelytocause,serious injury,harm,impairment,ordeathtoapatientandislikelytocontinue.Complaintsare assignedthispriorityiftheinformationindicatesimmediatecorrectiveactionis necessary.AllareimmediatelyreferredtoJointCommissionExecutiveLeadershipfor authorizationtoconductanunannouncedfor-causesurvey.Ifanon-site(for-cause) reviewisconducted,thehospitalwillbebilledasufficientcharge,basedonthe establishedfeeschedule,tocoverthecostsofconductingsuchasurvey. DisclosableInformation IfTheJointCommissionreceivesaninquiryabouttheaccreditationdecisionofa hospitalthathasexperiencedareviewablesentinelevent,thehospitalsaccreditation decisionwillbereportedintheusualmannerwithoutmakingreferencetothesentinel event.Iftheinquirerspecificallyreferencesthespecificsentinelevent,TheJoint Commissionwillacknowledgethatitisawareoftheeventandcurrentlyisworkingor hasworkedwiththehospitalthroughthesentineleventreviewprocess. SE14 CAMH,January2013 SentinelEventsÖ SubmissionofRootCauseAnalysisand ActionPlan ThehospitalthatexperiencesasentineleventsubjecttotheSentinelEventPolicyis askedtosubmittwodocuments:(1)thecompleterootcauseanalysis,includingits findings,and(2)theresultingactionplanthatdescribesthehospitalsriskreduction strategiesandmeasuresforevaluatingtheireffectiveness.Thisinformationwillbe submittedtoTheJointCommissionCentralOfficeusinganonlinerootcauseanalysis collectiontool,***alsoaccessiblefromtheContinuousComplianceToolssectionof theJointCommissionConnectextranetsite,undertheSentinelEventActivitieslink. Therootcauseanalysisandactionplanarenottoincludethename(s)ofcaregiversand patientsinvolvedinthesentinelevent. Alternatively,ifthehospitalhasconcernsaboutwaiversofconfidentialityprotectionsas aresultofsendingtherootcauseanalysisdocumentstoTheJointCommission,the followingalternativeapproachestoareviewofthehospitalsresponsetothesentinel eventareacceptable: 1.AreviewoftherootcauseanalysisandactionplandocumentsbroughttoJoint Commissionheadquartersbyhospitalstaff,thentakenbacktothehospitalonthe sameday 2.Anon-sitemeetingwithaspeciallytrainedJointCommissionstaffmembertoreview therootcauseanalysisandactionplan 3.Anon-sitevisitbyaspeciallytrainedJointCommissionstaffmembertoreviewthe rootcauseanalysisandfindingswithoutdirectlyviewingtherootcauseanalysis documentsthroughaseriesofinterviewsandareviewofrelevantdocumentation. Forpurposesofthisreviewactivity,relevantdocumentationincludes,ataminimum, anydocumentationrelevanttothehospitalsprocessforrespondingtosentinel events,thepatientsmedicalrecord,andtheactionplanresultingfromtheanalysisof thesubjectsentinelevent.Thelatterservesasthebasisforappropriatefollow-up activity. 4.Whenthehospitalaffirmsthatitmeetsspecifiedcriteriarespectingtheriskof waivingconfidentialityprotectionsforrootcauseanalysisinformationsharedwith TheJointCommission,anon-sitevisitbyaspeciallytrainedsurveyorisarrangedto conductthefollowing: a.Interviewsandreviewsrelevantdocumentation,includingthepatientsmedical record,toobtaininformationaboutthefollowing: ***AlsoreferredtoasAlternative0. CAMH,January2013 SE15 ÕComprehensiveAccreditationManualforHospitals QTheprocessthehospitalusesinrespondingtosentinelevents QTherelevantpoliciesandproceduresprecedingandfollowingthehospitals reviewofthespecificevent,andtheimplementationthereof,sufficientto permitinferencesabouttheadequacyofthehospitalsresponsetothe sentinelevent b.Astandards-basedsurveythattracesapatientscare,treatment,andservicesand thehospitalmanagementfunctionsrelevanttothesentineleventunderreview Alternatives1,2,3,or4willresultinasufficientchargetothehospitaltocoverthe averagedirectcostsofthealternative.InquiriesaboutthefeeshouldbedirectedtoThe JointCommissionsPricingUnitat630-792-5115. TheJointCommissionmustreceivearequestforreviewofahospitalsresponsetoa sentineleventusinganyofthesealternativeapproacheswithinatleastfivebusinessdays oftheself-reportofareviewableeventoroftheinitialcommunicationbyTheJoint Commissiontothehospitalthatithasbecomeawareofareviewablesentinelevent. TheJointCommissionsResponse JointCommissionstaffassesstheacceptabilityofthehospitalsresponsetothe reviewablesentinelevent,includingthethoroughnessandcredibilityofanyrootcause analysisinformationreviewedandthehospitalsactionplan.Iftherootcauseanalysis andactionplanarefoundtobethoroughandcredible,TheJointCommissionwill notifytheorganizationandassignoneormoreSEMOS.(SeetheSentinelEvent MeasuresofSuccesssectionformoredetails.) Iftheresponseisunacceptable,JointCommissionstaffwillprovideconsultationtothe hospitalonthecriteriathathavenotyetbeenmetandwillallowanadditional15 calendardaysbeyondtheoriginalsubmissionperiodforthehospitaltoresubmitits response. Iftheresponsedoesnotmeetestablishedcriteria,thehospitalsaccreditationdecision maybeimpactedifTheJointCommissiondeterminesthehospitalhasnotundertaken seriousimprovementefforts. Whenthehospitalsresponse(initialorrevised)isfoundtobeacceptable,TheJoint Commissionissuesaletterthatdoesthefollowing: Formoreinformationaboutthetracermethodology,seeTheAccreditationProcess(ACC)chapter. SE16 CAMH,January2013 SentinelEventsÖ QReflectstheJointCommissionsdeterminationtocontinueormodifythehospitals currentaccreditationdecision QAssignsanappropriatefollow-upactivity,typicallyoneormoreSEMOSduein fourmonths SentinelEventMeasuresofSuccess Thehospitalsfollow-upactivitywillbeconductedthroughtheMOSprocess.AnMOS isanumericalorquantifiablemeasureusuallyrelatedtoanauditthatdeterminesifa plannedactionwaseffectiveandsustained.TheSEMOSareduefourmonthsafterthe rootcauseanalysisandactionplanaredeterminedtobeacceptablebyTheJoint Commission.IftheplannedactioncanbeassociatedwithastandardorNationalPatient SafetyGoalrequirement,itwillhavealevelofcomplianceexpectationbasedonthetype ofelementofperformance(EP)fortheassociatedstandardorNationalPatientSafety Goalrequirement.Thatis,iftheactionisequivalenttoanEPthatisidentifiedasa CategoryAEP,thelevelofcomplianceexpectationfortheSEMOSforthatactionwill be100%.IftheactionisequivalenttoanEPthatisidentifiedasaCategoryCEP,the minimumrequiredlevelofcompliancefortheSEMOSforthatactionwillbe90%.If theactioncannotbeassociatedwithanexistingstandardorNationalPatientSafety Goalrequirement,thehospitalwillidentifythelevelofcomplianceexpectation,which mustbeatleast85%,subjecttoapprovalbyTheJointCommission. ThefollowinginformationfurtheroutlinestheSEMOSrequirement: QIfanSEMOSissubmittedontimebutdoesnotmeetestablishedlevelsof compliance,theJointCommissionstaffwillrequestanadditionalfourmonthsof data. QIfthesecondsetofdatadoesnotmeetestablishedlevelsofcompliance,the hospitalsaccreditationdecisionmaybeimpacted. QIfanSEMOSis90ormoredayslate,thehospitalsaccreditationstatusmaybe impactedifTheJointCommissiondeterminesthehospitalhasnotundertaken seriousimprovementefforts. Adecisiontomaintainorchangethehospitalsaccreditationdecisionasaresultofthe follow-upactivityortoassignadditionalfollow-uprequirementswillbebasedon existingdecisionrulesandthedeterminationofstaffintheSentinelEventUnit,unless otherwisedeterminedbytheAccreditationCommittee. CAMH,January2013 SE17 ÕComprehensiveAccreditationManualforHospitals HandlingSentinelEventRelatedDocuments Handlingofanysubmittedrootcauseanalysisandactionplanisrestrictedtospecially trainedstaffinaccordancewithproceduresdesignedtoprotecttheconfidentialityofthe documents. UponcompletionofTheJointCommissionreviewofanysubmittedrootcauseanalysis andactionplanandtheabstractionoftherequireddataelementsforTheJoint CommissionsSentinelEventDatabase,theoriginalrootcauseanalysisdocumentsand anycopieswillbedestroyed.Uponrequest,theoriginaldocumentswillbereturnedto thehospital.TheinformationcontainedinanyelectronicallysubmittedRCAtoolwill bede-identifiedoncethereviewiscompleted. Theactionplanresultingfromtheanalysisofthesentineleventwillinitiallyberetained toserveasthebasisfortheSEMOS.Oncetheactionplanhasbeenimplementedand meetstheestablishedlevelsofcomplianceasdeterminedthroughtheSEMOS,The JointCommissionwilldestroyanddeletetheactionplan.IftheSEMOSwassubmitted electronically,theinformationwilllikewisebede-identifieduponcompletionofthe review. OversightoftheSentinelEventPolicy TheAccreditationCommitteeofTheJointCommissionsBoardofCommissionersis responsibleforoverseeingtheimplementationofthispolicyandprocedure.Inaddition toreviewinganddecidingindividualcasesinvolvingchangesinahospitalsaccreditation decision,TheJointCommissionstaffwillperiodicallyaudittherootcauseanalysesand SEMOSandreportthesefindingstotheAccreditationCommittee.Forthepurposesof theseaudits,TheJointCommissiontemporarilyretainsrandom(de-identified)samples ofthesedocuments.Uponcompletionoftheaudit,thesedocumentsarealsodestroyed. FormoreinformationaboutTheJointCommissionsSentinelEventPolicyand Procedures,visitTheJointCommissionswebsiteathttp://www.jointcommission.orgor calltheSentinelEventHotlineat630-792-3700. SE18 CAMH,January2013