The Joint Commission is an independent, not-for-profit organization that accredits and certifies the vast majority of hospitals in the U.S. It sets the standards under which accredited hospitals must operate and makes periodic site visits to “grade” the extent to which those standards are being met. The Joint Commission has established standards for such topics as: correctly identifying patients, improving staff communications, labeling of drugs, infection control measure, identifying patient safety risks, and preventing mistakes in surgery. One example was the standards to prevent wrong-site or wrong-patient surgeries: it mandated a “time out” just before surgery so all participants understand and agree on what surgery is being performed on what part of the body.
One of its programs to improve the quality of health care is a review of hospital’s responses to “sentinel events.” A sentinel event is an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.” Serious injury includes loss of limb or function. The point is to identify specific events for which a recurrence would carry a significant chance of a repeat serious adverse outcome.
Such events are called ‘sentinel’ because they signal the need for immediate investigation and response. As part of its evaluation of how hospitals are handling such sentinel events, the Joint Commission conducts announced accreditation surveys as well as random unannounced surveys. A sentinel event can occur in any activity occurring at a hospital, including obstetrics, emergency room care, surgeries, infection treatment, and post-op care.
It is very likely that the recent snafu in Houston, in which a sick patient had just arrived from Liberia but that information was not forwarded by the nursing staff to the ER physicians, will be the subject of a sentinel event evaluation. It was an error that could have resulted in a patient with Ebola being released into the public and the start of a serious public health problem. The sentinel event process is intended to determine why the mistake occurred and identify the means of preventing it from occurring in the future. This knowledge can then be utilized by the Joint Commission in advising other hospitals on ways to avoid a similar serious mistake.
The Joint Commission publishes frequent reports that cover the many types of sentinel events that are reported and how they are being handled by hospitals. Its website at www.TheJointCommission.org” can be accessed by the public.
