Reportable serious events can be divided into the following categories: In addition to the above list, the Joint Commission requires each accredited organization to define sentinel events for its own procurement system and establish monitoring procedures to detect these events as well as a root cause analysis procedure. If a sentinel event is (re)identified as part of normal surveying activities, the investigator takes the following actions: â A sentinel event is an unexpected event resulting in death or serious physical or psychological injury or the risk of such an event. Serious injuries include, in particular, loss of limbs or function. The phrase “or likelihood of such a change” includes any procedural change the recurrence of which would result in a substantial likelihood of a serious adverse outcome. The hospital must review all sentinel events. All accredited hospitals are encouraged, but are not required to report every Sentinel event to the Joint Commission. Since 2007, approximately 800 sentinel events have been reported to the Joint Commission each year, based on its sentinel event summary data. Sentinel events occur in all health systems. The vast majority of them occur in a medical-surgical hospital, followed by psychiatric hospitals (including psychiatric units and clinics) and emergency departments. More than three-quarters of them are voluntarily reported to the Agency.
The most common sentinel events are surgery in the wrong place, foreign body retention and falls.  This is followed by suicide, delayed treatment and medication errors. The risk of suicide is highest immediately after hospitalization, during hospitalization or immediately after discharge. Fortunately, the discharge of infants into the wrong family has been reduced to zero. Haemolytic transfusion reactions due to major blood group incompatibilities are always reported with an incidence of 7 to 9 per year. The accreditation body received 1,197 sentinel event reports last year, 89% of which were voluntarily reported by health organizations. In 2020, a total of 809 events were reported. This total had already peaked in 2012, when 946 sentinel events were reported. After reviewing the accredited entity`s report on the sentinel event, the Joint Commission will prepare a formal accreditation decision report, which may change the organization`s current accreditation status, assign an appropriate “success measure,” or require a follow-up survey within six months. A health facility that fails to conduct a root cause analysis of the Sentinel event and action plan within the allotted time may be placed under “accreditation monitoring” by the Joint Commission, a status that may be publicly announced. The Joint Commission issues “sentinel event alerts” that identify specific sentinel events, their underlying causes, and measures to prevent recurrence.  Request an example of a root cause analysis conducted last year to assess the appropriateness of the hospital-based sentinel response process.
Other examples can be reviewed as needed to better assess the hospital`s understanding and ability to conduct root cause analysis. When choosing an example, the hospital may choose a “closed case” or a “near miss” to demonstrate its sentinel event response procedure. Every healthcare organization should have a step-by-step crisis management plan for the effective and respectful management of a Sentinel event. Appropriate disclosure of adverse events to patients, including risk management, is required. Several states require full disclosure of errors. The goal of RCA2 is to identify and mitigate system errors and prevent future occurrences. A collaborative interprofessional team approach is required for successful and timely implementation. Strong metrics help standardize and simplify the workflow process. The process aims to continuously improve and promote patient- and family-centred care. It is a step towards improving the organizational culture of safety and promoting a fair, non-punitive and equitable culture. An interprofessional team needs people with leadership skills who participate in the process under consideration and contribute to effective analysis. Where appropriate, patients or family representatives should also be involved.
All important information is gathered through individual and group interviews, medical records and literature reviews. Various tools such as flowcharts, Pareto charts, affinity charts, and chevron charts are used to visualize and organize information.    The Pareto principle is based on the 80-20 rule that 80% of problems are due to 20% of causal causes. A Pareto chart helps prioritize quality improvement efforts by identifying areas of maximum potential impact. A Pareto chart is like a frequency chart to understand the variability of continuous measurements. The flowchart breaks down the successive steps of a complicated process and the possible steps to make improvements. For example, an organizational chart can help improve workflow, eliminate waste, and improve performance. A fishbone diagram (also known as an Ishikawa diagram or cause-and-effect diagram) is a quality improvement tool that helps organize the various potential causes that contribute to an outcome. It can be used to categorize various causes (e.g., processes, people, policies, equipment, materials). It does not identify the frequency of events.
Affinity diagrams help organize brainstorming ideas into groups. Specific categories of security solutions (training, policy, consulting, compliance audit, institutional, information technology, physical environment, form/paperwork) can be developed to prevent future adverse events.   The Patient Safety Systems chapter provides a framework based on Joint Commission standards on which hospitals can build their integrated patient safety system – where staff and managers work together to eliminate complacency, promote collective mindfulness, treat each other with respect and compassion, and learn from patient safety events. Asking hospital leaders and staff about their expectations and responsibilities for identifying, reporting and responding to SEMOS sentinel events is a quantifiable measure to assess whether the action plan was effective and sustainable. It has a numerator and a denominator. The organization tracks data through inspection and record observation to measure compliance. Each organization should have a clear framework for reporting and responding to a sentinel event that is non-punitive, encourages teamwork, and fosters a just culture. During the on-site interview, the assessor assesses the hospital`s compliance with sentinel event standards as follows: “Inform the CEO that the event has been identified Hospitals differ in their definitions, surveys and reports of sentinel events. Examples of Joint Commission sentinel events include: The Joint Commission collects and analyzes data from sentinel events reviewed and reported by organizations. Anonymized data contributes to the general awareness and dissemination of error prevention strategies in all hospitals.
The Joint Commission website offers sentinel event resources, statistics, webinars and quick safety tips.  “The terms `sentinel event` and `error` are not synonymous; Not all Sentinel events occur due to an error, and not all errors result in Sentinel events. An event is also considered a guardian if it is one of the following: During an accreditation survey, the accrediting body attempts to assess the hospital`s compliance with applicable standards, national patient safety objectives, and accreditation participation requirements, and assess these requirements against performance across the hospital over time. Land surveyors are instructed not to search for sentinel events or to inquire about sentinel events reported to the accrediting body during a typical survey. Evaluators can conduct an assessment of a hospital`s performance improvement practices and procedures, such as root cause analysis and proactive risk assessment. â Inform the CEO that the event will be reported to the accrediting body for further review and follow-up in accordance with the provisions of the Sentinel Events Policy. The evaluator does not decide whether the event is a verifiable Sentinel event or not, but forwards subsequent discussions to the accreditation body of the Sentinel Events Unit of the Office of Quality Surveillance. Reporting a sentinel event to the Joint Commission is voluntary.  The benefits of reporting the sentinel event include: “Such events are called `sentinels` because they signal the need for immediate investigation and response.
A sentinel event is a patient safety event (not primarily related to the natural history of the patient`s disease or underlying disease) that affects a patient and leads to one of the following events: A sentinel event is defined by the U.S. accrediting body The Joint Commission (TJC) as any unforeseen event in a healthcare facility that results in death or serious physical or psychological consequences. Injuries to one or more patients. is not associated with the natural course of the patient`s disease.