Sentinel event

A sentinel event is defined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a person or persons, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under JCAHO accreditation policies to help aid in root cause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated.

pecific events requiring review

Besides "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof", sentinel events also include the following, even if the outcome was not death or major permanent loss of function:
* Infant abduction, or discharge to the wrong family.
* Unexpected death of a full term infant.
* Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).
* Surgery on the wrong individual or wrong body part.
* Surgical instrument or object left in a patient after surgery or another procedure.
* Rape in a continuous care setting.
* Suicide in a continuous care setting, or within 72 hours of discharge.
* Hemolytic transfusion reaction due to blood group incompatibilities. [A fatal tranfusion reaction must be reported within 7 days.]
* Radiation therapy to the wrong body region or 25% above the planned dose.

In additional to the list above, JCAHO requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis.

Actions and reporting

Participation is necessary by the leadership of the organization and by the persons closely involved in the systems under review. Causal factors are analyzed, focusing on systems and processes, not individual performance. Potential improvements, called an "action plan", are identified and implemented to decrease the likelihood of such events in the future. Each accredited organization is encouraged, but not required, to report any sentinel event to JCAHO. However, the organization is expected to prepare a root cause analysis and action plan within 45 calendar days of the event.

Advantages of reporting sentinel events to JCAHO are:
*Adding to the database with dissemination to other health care facilities, preventing other adverse events.
*Consultation with JCAHO on implementing the root cause analysis and action plan.
*Association with national accrediting body reassures the public that all steps are being taken to prevent a recurrence.

JCAHO actions

After review of the accredited facility's report on the sentinel event, Joint Commission issues an Official Accreditation Decision Report that may modify the organization's current accreditation status, assign an appropriate "measure of success", or a require follow-up survey within six months. A healthcare facility that fails to complete a root cause analysis of the sentinel event and action plan within the time frame can be placed on "Accreditation Watch" by the Joint Commission, a status that can be publicly disclosed . JCAHO disseminates "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence. [Joint Commission on Accreditation of Healthcare Organizations: [http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/ Sentinel Event Alerts] ]

External links

* [http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/ JCAHO Sentinel Events Policy and Procedure]

Notes