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– JCAHO –
IV. Reviewable Sentinel Events

Definition of Occurrences that are Subject to Review by the
Joint Commission under the Sentinel Event Policy

Adapted from JCAHO June 2005 Sentinel Event Policy and Procedures

The subset of sentinel events that is subject to review by the Joint Commission includes any occurrence that meets any of the following criteria:

  • •   The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient's illness or underlying condition,[1], [2], [3] or
  • •   The event is one of the following (even if the outcome was not death or major permanent loss of function unrelated to the natural course of the patient's illness or underlying condition):
    • ◊  Suicide of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge.
    • ◊  Unanticipated death of a full-term infant
    • ◊  Abduction of any individual receiving care, treatment or services (Added to list since 2004)
    • ◊  Discharge of an infant to the wrong family (Revision since 2004)
    • ◊  Rape [4]
    • ◊  Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
    • ◊  Surgery on the wrong patient or wrong body part [5]
    • ◊  Unintended retention of a foreign object in an individual after surgery or other procedure (Added to list since 2004)
    • ◊  Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter) (Added to list since 2005)
    • ◊  Prolonged fluoroscopy with cumulative dose >1500 rads to a single field, or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose (Added to list since 2005)

  • 1 – A distinction is made between an adverse outcome that is primarily related to the natural course of the patient's illness or underlying condition (not reviewed under the Sentinel Event Policy) and a death or major permanent loss of function that is associated with the treatment (including "recognized complications") or lack of treatment of that condition, or otherwise not clearly and primarily related to the natural course of the patient's illness or underlying condition (reviewable). In indeterminate cases, the event will be presumed reviewable and the organization's response will be reviewed under the Sentinel Event Policy according to the prescribed procedures and time frames without delay for additional information such as autopsy results.
  • 2 – “Major permanent loss of function” means sensory, motor, physiologic, or intellectual impairment not present on admission requiring continued treatment or life-style change. When major permanent loss of function cannot be immediately determined, applicability of the policy is not established until either the patient is discharged with continued major loss of function, or two weeks have elapsed with persistent major loss of function, whichever occurs first.
  • 3 – For laboratories, as required by standard QC.5.280, a confirmed fatal transfusion reaction must be reported to the FDA Center for Biologics and the Joint Commission within seven days.
  • 4 – Rape, as a reviewable sentinel event, is defined as unconsented sexual contact involving a patient and another patient, staff member, or unknown perpetrator while being treated or on the premises of the health care organization, including oral, vaginal or anal penetration or fondling of the patient's sex organ(s) by another individual's hand, sex organ or object. One or more of the following must be present to determine reviewability:
    • •  Any staff witnessed sexual contact as described above
    • •  Sufficient clinical evidence obtained by the organization to support allegations of unconsented sexual contact
    • •  Admission by the perpetrator that sexual contact, as described above, occurred on the premises.
  • 5 – All events of surgery on the wrong patient or wrong body part are reviewable under the policy, regardless of the magnitude of the procedure.

Also note that JCAHO provides additional interpretive guidelines with examples of Reviewable Sentinel Events.

This web page is adapted directly from JCAHO's Sentinel Events Policies and Procedures

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