Question

Discuss JCAHO’s efforts to ensure patient safety, specifically addressing the tracer methodology and sentinel events. (25 points) (A 1½-page response is required.)

Answer 1

Ans) Each hospital is encouraged, but not required, to report to The Joint Commission any sentinel event meeting the criteria for reviewable sentinel events. Alternatively, The Joint Commission may become aware of a sentinel event by some other means such as communication from a patient, a family member, an employee of the hospital, or a surveyor, or through the media.

Reasons for Reporting a Sentinel Event to The Joint Commission:
- Although self-reporting a sentinel event is not required and there is no difference in the expected response, time frames, or review procedures, whether the hospital voluntarily reports the event or The Joint Commission becomes aware of the event by some other means, there are several advantages to the hospital that self-reports a sentinel event:
The Reporting the event enables the addition of the “lessons learned” from the event to be added to The Joint Commission’s Sentinel Event Database, thereby contributing
to the general knowledge about sentinel events and to the reduction of risk for such events in many other hospitals.
In Early reporting provides an opportunity for consultation with Joint Commission staff during the development of the root cause analysis and action plan.
- The hospital’s message to the public that it is doing everything possible to ensure that such an event will not happen again is strengthened by its acknowledged collaboration with The Joint Commission to understand how the event happened and what can be done to reduce the risk of such an event in the future.

Required Response to a Reviewable Sentinel Event:
- If The Joint Commission becomes aware (either through voluntary self-reporting or otherwise) of a sentinel event that meets the criteria of this policy and the event has occurred in an accredited hospital, the hospital is expected to do the following:
- Prepare a thorough and credible root cause analysis and action plan within 45 calendar days of the event or of becoming aware of the event andand Sub to The Joint Commission its root cause analysis and action plan, or
otherwise provide for Joint Commission evaluation of its response to the sentinel event under an approved protocol (see Section VI), within 45 calendar days of the
known occurrence of the event.
- The Joint Commission will then determine whether the root cause analysis and action plan are acceptable. If the determination that an event is reviewable under the Sentinel
Event Policy occurs more than 45 calendar days following the known occurrence of the event, the hospital’s response will be due in 15 calendar days. If the hospital has failed to
submit a root cause analysis within an additional 45 days following its due date, its accreditation decision may be impacted.

- The Joint Commission is committed to developing and maintaining this Sentinel Event Database in a fashion that will protect the confidentiality of the hospital, the caregiver, and the patient. Included in this database are three major categories of data elements:
1. Sentinel event data
2. Root cause data
3. Risk reduction data