The JCAHO and Sentinel Events

The JCAHO and Sentinel Events
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The JCAHO and Sentinel Events
Sentinel events are unexpected occurrences that involve death or serious psychological or physical injury. Sentinel event reporting is of major importance since it will broaden The Joint Commission’s database of sentinel events. In turn, this will enhance knowledge regarding sentinel events and help in reducing the risk of these events occurring in other health facilities (Sorbello, 2008). Reporting a sentinel event early enough allows for consultation with the Commission employees in the development of the root-cause analysis as well as an action plan. Furthermore, the message by the healthcare organization that it is actually doing all it can to make sure that such events would never occur again is strengthened by its cooperation with the Commission to understand the way the event occurred and how such an event could be prevented from occurring again (The Joint Commission, 2014).
The general requirements of The Joint Commission’s Sentinel Event policy are as follows: every accredited healthcare organization should define sentinel event for its own purposes and it is expected to communicate this definition of sentinel event to every staff throughout the facility (The Joint Commission, 2014). An organization’s definition of a sentinel event should incorporate those pertinent events which are subject to review under the Sentinel Event Policy. The other requirement is that accredited organizations have to identify and respond in an appropriate way to every sentinel event that occurs within the organization or associated with services, treatment or care that the facility provides, or provides for. Health care facilities are required to carry out a root-cause analysis in order to identify the contributing factors within a period of 45 days after a sentinel event or being aware of the event (Heitmiller, 2011).
As the product of root cause analysis, an action plan needs to address responsibility for implementation, time lines, oversight, pilot testing as apt, as well as strategies for assessing the efficacy of the action (The Joint Commission, 2014). In ensuring patient safety, the role of The Joint Commission is to review the activities of health care facilities in response to sentinel events in its process of accreditation, including all random unannounced surveys and full accreditation surveys, and as apt, for-cause surveys specific to Evidence of Standards Compliance (The Joint Commission, 2014).
Root-cause analysis is understood as a process that is used to identify factors that bring about variation in performance, including the possible or actual incidence of a sentinel event. It is of note that the main focus of a root-cause analysis is on processes and systems rather than on individual performance (Heitmiller, 2011). The process of conducting a root-cause analysis progresses from special causes in clinical processes to the common causes in organizational systems and processes, for instance defense systems. It identifies the possible improvements in these systems or processes that would be inclined to re...