On October 23, 1998, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released to all accredited organizations new policies and procedures for responding to sentinel events. Your Chief Executive Officer should have received these documents via a "Dear Colleague" letter. The new policies were developed to respond to the concerns of many hospitals and healthcare organizations regarding the risks of sharing a root cause analysis. The new policies give organizations several options for sharing sentinel event information with JCAHO. From a risk management perspective, concerns continue about the possible waiver of legal protection for root cause analyses that are sent to the Joint Commission.
It is important to remember that self-reporting of sentinel events to JCAHO continues to be voluntary. Hospitals and healthcare organizations should carefully consider a decision to self-report a sentinel event to JCAHO. Whether or not a sentinel event is self-reported, JCAHO expects any hospital or healthcare organization to complete a timely root cause analysis and to develop, implement, and monitor the effectiveness of an action plan. Healthcare organizations and professionals are encouraged to develop a sentinel event policy and procedure which considers state laws and the implications of sharing a root cause analysis with a third party. The decision of whether to report should not distract the risk management focus on the causation factors contributing to the event and process improvements to prevent recurrence.
Information regarding the JCAHO’s new sentinel event policies and procedures, as well as ASHRM Member Alerts, is available on the ASHRM web site. JCAHO also has a web site (www.jcaho.org). Members can also contact JCAHO's hotline (630)792-3700 for clarification of any questions related to the new sentinel event policies and procedures.
Another source for information on sentinel events is ASHRM's Fax-On-Demand Service. Located on this service, you can obtain a copy of a recent presentation given by Dr. Rick Croteau, JCAHO's Executive Director, Strategic Initiatives. He spoke at the "Enhancing Patient Safety and Reducing Errors in Healthcare" meeting at the Annenberg Center. His presentation contains statistics on sentinel events as well as information on the process and reporting options. To receive this document, simply dial: 1-800-764-3294 and enter document #432209.
ASHRM would appreciate hearing of your experiences with JCAHO following sentinel events that have occurred at your organization. Please take a few minutes to complete the attached survey, if JCAHO has been involved in the investigation process, and send it to ASHRM at: One North Franklin, Chicago, IL 60606 or fax: (312)422-4580. You may also access additional copies of the survey via ASHRM's web site and fax-on-demand service - document #432212. We will advise you of the results in a future issue of ASHRM's Forum newsletter.
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American Society for Healthcare Risk Management
Survey - Experiences with JCAHO Sentinel Event Process
The purpose of this form is to provide risk management professionals with a communication tool to share anonymously their experiences, as they occur, with the sentinel event reporting/investigation process. Data will be complied and reported to ASHRM members on a routine basis in an effort to maintain awareness of experiences reported by other institutions following JCAHO's intervention following a sentinel event. After completion, please fax your response to Christy Kessler at ASHRM (312) 422-4580 or mail them to: Christy Kessler, ASHRM, One North Franklin, Chicago, IL 60606.
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(this is not an interactive form, please print out and complete)
Location of Event
Med/Surg Hospital
Obstetrics
Emergency
Critical/Special Care
Outpatient Surgery
Long term care facility
Home Health Agency
Other __________
Psychiatric Hospital
Geropsych Unit
Adolescent Unit
Partial Program
Other __________
Type of Event
Unanticipated Death
Major Permanent Loss of Function
Patient Elopement
Patient Suicide
Infant Abduction
Perinatal Death greater than or equal to 2500 grams
Infant Discharge to Wrong Family
Intrapartum Maternal Death
Rape
Hemolytic Blood Transfusion Reaction
Surgery on Wrong Patient or Wrong Body Part
Patient Death, Paralysis, Coma or Major Permanent Loss of Function Associated with a Medication Error
Description of Sentinel Event (optional)
_________________________________________________
_________________________________________________
_________________________________________________
1. How did JCAHO learn about the event? (check all that apply)
Self-Reported
Routine Survey
Newspaper
Anonymous Call
Patient/Family Complaint
Notification by State/HCFA Agency
Staff Complaint
Other __________
2. Decision to Self Report Determined by (check all applicable)
JCAHO Hotline Discussion
Medical Staff Committee
Risk/Quality Manager
Chief Executive Officer
Automatic Report per Hospital Policy
Other __________
N/A-no self report
3. How long after the event did JCAHO learn about it?
0-3 days
4-7 days
8-30 days
Other __________
Unknown when JCAHO knew
4. Hospital initiated reporting process
Self reported within 5 days on prescribed form and
Root cause analysis (RCA) submitted within 45 days
RCA presented at JCAHO Headquarters and documents left
Onsite RCA review requested and conducted and copies given to JCAHO
Onsite RCA review requested and conducted and no copies given to JCAHO
Onsite survey to discuss process-RCA not reviewed.
No self-report
5. After JCAHO became aware of event, when was the facility first contacted by JCAHO?
0-3 days after JCAHO’s awareness of event
4-7 days after JCAHO’s awareness of event
8-14 days after JCAHO’s awareness of event
Other __________
Unknown
6. What was JCAHO’s initial response?
Scheduled site visit within ______ days weeks
Requested submission of root cause analysis for review
Made unannounced visit Requested letter/narrative description of event
Determined event not reportable under JCAHO policy
Other __________
7. Did your facility perform a root cause analysis of the event?
Yes No
If Yes:
a. Was the JCAHO format used? Yes No
If yes, was it useful? Yes No
Comments _____________________________________
_____________________________________
_____________________________________
If no, what format was used? (attach blank form if willing to share)
b. Was it completed within 45 days of event?
Yes No
If no, what was pending?
Analysis incomplete
Corrective actions not completed
Other __________
c. Number of members on root cause analysis team: _____
Please list positions of each member: ________________________________
________________________________
________________________________
d. Estimated time required to complete root cause analysis (Total personnel hours):
