1. Section Editor(s): Jackson, Rita PhD, RD

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It has been 10 years since the Joint Commission adopted its policy to review the responses by health care organizations to sentinel events. Since 1995, health care organizations have been encouraged to voluntarily report all sentinel events, which are defined as unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. These events are called "sentinel" because they should trigger immediate investigation and response by the organization. The phrase "or the risk thereof" includes "any process variation for which a recurrence would carry a significant chance of a serious adverse outcome."1


The Joint Commission becomes aware of sentinel events directly from heath care organizations and from patients or family members, employees of the organization, the media, or from surveyors' reports. Thus far, 63.6% of the reports have come from organizations; 10.4% from complaints; 8.9% from the media; 7.6% during Joint Commission surveys; and 5.4% from the Centers for Medicare & Medicaid Services (CMS) or state reports. A total of 2,966 reports were received by the Joint Commission between 1995 and 2004, and it has been estimated that this reflects only 1% of the events that actually occur in the industry.


The rate of reporting has been low due to the voluntary nature of the program and because the Joint Commission feels that there is a misunderstanding regarding the potential impact a report may have on an organization's accreditation status. It says that accreditation status will not be affected if the organization follows the steps required in response to a reported sentinel event. These steps include a 45-day root cause analysis period, and Joint Commission staff works with the organization through its sentinel event review process to provide assistance and help prevent similar events in the future. Of course, there have also been legal concerns on the part of health care organizations regarding the possibility of the data being used against them in the courts. But, according to the Joint Commission, legally protected sentinel event-related information will not be disclosed to any other party, and it "will vigorously defend the legal confidentiality of this information, if necessary, in the courts."1


Even though the response rate has been low, some things have been learned from the Joint Commission's sentinel event policy thus far. For example, the root cause that has been most frequently found since 1995 (66% of reported sentinel events) is communication, and the second most frequent cause relates to orientation and training (57%). Root cause analysis has also revealed issues related to patient assessment processes (42%), staffing levels (22%), information availability (20%), competency/credentialing (20%), and procedural compliance (19%). This leads us back to things that good managers and administrators have known all along-when an adequate number of competent and well-trained staff members are employed and these people work together to share information and follow standards, negative outcomes can be minimized.


Don't forget to focus on staff competency in environment of care issues such as codes and life safety.




1. The Joint Commission's Sentinel Event Policy: ten years of improving the quality and safety of health care. Joint Commission Perspectives. 2005; 25(5):1, 3-5. (Also see sentinel event criteria at [Context Link]


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Rita Jackson, PhD, RD


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Fernandina Beach, FL 32035