New Sentinel Event Policy Works to Make Health Care Even Safer for Patients Around the Globe

Despite the many success stories shared by patients who travel outside their country for care, adverse events in health care know no borders. Unanticipated health care events are not only tragic for the patients who are harmed by them, they are also tragic for the caregivers who have dedicated their lives caring for patients. Those who are involved in medical travel, both as caregivers and patients, should be cognizant of these issues and what actions should be taken to mitigate their risk.

At Joint Commission International (JCI), we are working with hospitals around the world to minimize these undesirable health care events by creating a culture of safety in which errors are identified and reported, and staff members work in a “no blame” atmosphere in which patient safety is an important part of the daily routine of health care providers.

With the recent release of the 3rd edition of the JCI hospital accreditation standards, we introduced the international health care community to the terms “sentinel, adverse, and near miss” that relate to the level of severity of undesirable health care events.

In March, we published a book entitled Understanding and Preventing Sentinel and Adverse Events in Your Health Care Organization. This book is designed to assist hospitals in meeting the new JCI requirements to develop their own definition of a sentinel event and establish a process to investigate a sentinel event when it occurs.

JCI considers a sentinel event to be an “unanticipated occurrence involving death or major permanent loss of function, or an event that happens as a result of wrong site, wrong patient, or wrong procedure surgery.” JCI’s definition of a sentinel event must be included in a hospital’s definition, and therefore should be considered the baseline definition.

JCI defines an adverse event as an unanticipated, undesirable, or potentially dangerous occurrence in a health care organization, such as a hospital-associated infection or a patient fall. A near miss is a process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome, such as almost giving a patient the wrong dose of a medication.

JCI’s sentinel event requirements are based on the respected approach developed by The Joint Commission over the last decade (JCI is the international affiliate of the U.S.-based Joint Commission.) The Joint Commission developed its sentinel event requirements in 1995 after a series of highly-publicized events led the public to question the safety and quality of accredited facilities.

The new requirements have led to a more consistent and rigorous process to investigate sentinel events using Root Cause Analysis, a tool industry has been using for many years. Once the underlying cause is known, the “system” weaknesses that permitted the error from reaching the patient can be fixed to prevent the event from happening again. System thinking is key to fixing the problem.

Despite their best efforts, excellent health care organizations around the world occasionally experience sentinel events. When they do, we encourage them to reach out to JCI so that we may work with them to ensure they truly understand the root cause of the event and then to strengthen their system of care so the event is unlikely to happen again.

Why is all this important for the medical traveler? First, JCI accredited hospitals are required to have data on sentinel and adverse event occurrences, the root cause of those events, and how they fixed the systems related to the events. Second, JCI accredited hospitals work to create a patient safe culture and do not engage in shame, blame, and cover up of adverse events. They learn from the events and move on.

Medical travelers should be wary of any hospital that reports that such events do not happen at their facilities. Finally, JCI accredited hospitals are required to have a process to inform patients and their family when an adverse event occurred during their care, and support the patient and their family with clear and consistent communications in the aftermath of the event. Patients should know the impact of the event on their care outcomes and what to expect regarding needed follow-up care.

Transparency is one of the most important elements of a patient safe culture in a hospital and one of the most important signs to a medical traveler that the hospital is a desirable care destination.

Karen H. Timmons is President and CEO of Joint Commission International, an international healthcare accreditation system.

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