During recent consultations, we’ve noticed that some organizations haven’t updated their sentinel event policy to include all the current TJC requirements. So, the following is a recap of TJC requirements related to sentinel events.

In 2013, TJC expanded its Sentinel Event Policy to include certain harmful events involving staff, visitors, or vendors that occur while these individuals are on the premises of the healthcare organization.  The specific change to the policy was that the list of “reviewable sentinel events” was expanded to include “Rape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the health care organization.”

The rationale for expanding the Sentinel Event Policy was to promote improved security and safety throughout the overall environment regardless of who the victim is. Since these specific types of incidents are now categorized as “reviewable sentinel events,” organizations are required to conduct a root cause analysis (RCA) if such an event occurs. If TJC becomes aware of the event, the organization is required to share its RCA, corrective actions, and associated measurement activities with TJC’s Office of Quality Monitoring.

In addition, it’s important to be aware of the following key points related to TJC’s Sentinel Event Policy:

• Reporting a sentinel event to TJC is still voluntary. Organizations are encouraged, but not required, to report sentinel events to TJC.
• TJC has a definition of “reviewable sentinel events”. This means that this subset of sentinel events is subject to review by TJC. There are other types of sentinel events that are not subject to review by TJC.
• This subset of reviewable sentinel events as defined in the Behavioral Health Standards Manual includes the following:
  • Any occurrence that has resulted in an unanticipated death or major permanent loss of function not related to the natural course of the individual’s condition” AND the following occurrences (even if the outcome was not death or major permanent loss of function):
  • Suicide of any individual served receiving care, treatment, or services in a staffed around-the-clock care setting or within 72 hours of discharge from a 24 hour setting
  • Abduction of any individual served receiving care, treatment, or services
  • Sexual abuse/assault (including rape)
  • Rape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the health care organization
• Note: The Hospital Standards manual (under which psychiatric hospitals are surveyed) has a definition of reviewable sentinel events that, in addition to the above, also includes occurrences applicable to hospital settings.
• If TJC becomes aware of a reviewable sentinel event (either through voluntary self-reporting or from another source), the organization must do the following:
  • Prepare a thorough and credible RCA and action plan within 45 days of becoming aware of the event.
  • Submit to TJC its RCA and action plan or otherwise provide for TJC’s evaluation of its response to the sentinel event under an approved protocol within 45 days of the known occurrence of the event

So, make sure your policy and practices related to sentinel events conform to these requirements. If, unfortunately, a sentinel event occurs, you want to be ready to move forward quickly to conduct your RCA and action plan and your policy should guide that important process.