Be aware that TJC has revised its Sentinel Event Policy and the Sentinel Event chapter in both the Hospital and Behavioral Health manuals. The revisions were effective January 1, 2015. While the essential components of the Sentinel Event Policy have not changed, there are some new terms and definitions that are important to be aware of:

New Terminology

The term “the risk thereof” (which left much room for interpretation) has been removed from the definition of sentinel event. It has been replaced with the term “severe temporary harm” which is defined as “critical, potentially life threatening harm lasting for a limited time with no permanent residual but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life threatening condition, or additional major surgery, procedure, or treatment to resolve the condition.”

The term “comprehensive systematic analysis” has been introduced. A root cause analysis (RCA) is one type of comprehensive systematic analysis. The rationale given by TJC at Hospital Executives Briefings was that organizations want more flexibility to use tools and approaches other than just the RCA model.

The term “patient safety event” has been introduced. It refers to a broader category of events and sentinel events are one type of patient safety event. In keeping with this definition, standard LD.04.04.05 EP 7 in the Leadership chapter has been revised. It now requires organizations to define patient safety events (not just sentinel events) and to communicate this definition throughout the organization.

TJC Follow-Up

The follow-up by TJC in response to a sentinel event has been expanded. The current follow-up typically consists of requiring the organization to submit Measures of Success due to TJC in four months. The new policy expands this to “mutually agreed-upon documentation of sustained improvement and reductions of risk, which may include one or more Sentinel Event Measures of Success.” The rationale is that Measures of Success alone do not guarantee sustained improvement and thus additional types of follow-up activities may be in order.

What does your organization need to do to be in compliance?

• Review the 2015 Sentinel Event chapter in your accreditation manual. Make sure that if a sentinel event occurs, you are following the 2015 requirements.
• Revise your organization’s Sentinel Event Policy to reflect the terminology change from “risk thereof” to “severe temporary harm.”
• Consider if you want to change your policy to reflect “comprehensive systematic analysis” or just stick with RCA.
• Make sure your policy includes a definition of “patient safety events.”
• When developing corrective actions and risk reduction activities in response to a sentinel event, be sure to closely track their implementation and monitor for sustained improvement. We have seen some organizations do a great job with corrective action plans and then falter on monitoring the implementation of the corrective actions and the effectiveness of the changes.

Heads Up: Be prepared for close scrutiny of sentinel events and complaints by the Office of Quality and Patient Safety which is headed by Dr. Ana McKee Chief Medical Officer. This topic has been emphasized at all recent TJC conferences as well as the TJC Consultants Forum and we have seen closer attention by TJC to sentinel events and complaints with several of our clients this past year.