July 12, 2001 Home Return to Articles Return to March magazine
Following a five-year study of Sentinel Events (i.e., errors that lead to patient death or disability), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has now put into effect its new Sentinel Event Policy and Procedures — a set of accreditation standards that will hopefully lead to significant improvements in hospital safety.
Goals of the New Policy
The new Policy, effective July 1, was designed, according to Dr. Dennis O'Leary, president of the Joint Commission, to ''create a culture of safety'' wherein caregivers are not afraid to report errors.
The new Policy itself states that one goal is ''to focus the attention of an organization that has experienced a sentinel event on understanding the causes that underlie the event, and on making changes in the organization's systems and processes to reduce the probability of such an event in the future.''
Sentinel Events Must Be Reported
The guts of the new Policy is that Sentinel Events must be reported to JCAHO, along with a ''root cause analysis'' of what went wrong and what is being done to prevent future occurrences. Where the information is legally sensitive, it may be brought to Commission headquarters and carried away again, or viewed on-site. In some cases, studies of the Event will take place and new safety procedures will be designed.
Noncompliance with this new Policy threatens the healthcare organization with being placed on Watch Alert status. This threat provides a strong sanction for compliance, because Watch Alert status is a matter for public disclosure.
Patients Must Be Told?
The most controversial aspect of JCAHO's new Sentinel Event Policy and Procedures is the requirement that patients (or survivors) be told of the occurrence of an error that led to harm or death. But the actual wording of the Policy provides no sanctions to enforce this aspect, apparently because of the legal issues involved when a hospital informs people that harm has been done to them or their loved ones in the process of care.
At the press conference announcing implementation of the new Policy, the legal aspects of such disclosure were discussed at length. One reporter pointed out that the ''liability law needs to be changed so that doctors can come forward without fear of legal retribution.'' (Numerous bills have been before Congress in an attempt to change the liability laws, but none of them has been passed.)
Dr. O'Leary answered: ''[W]e have been strong proponents for federal legislation to protect the confidentiality of reported events and their underlying analyses, but we think ... we're more likely to be successful if we place that under the rubric ''peer review protection'' ... rather than tort reform.'' He added that the pending Jeffers-Kennedy-Fritz bill in the Senate addresses protecting the confidentiality of peer review, rather than promoting overall reform of the way malpractice lawsuits are handled by our judicial system.
To hear a replay of the press conference on the new patient safety standards call 800-642-1687; the conference number ID is 1248472. To read the JCAHO study and the entire text of the new Sentinel Event policies, visit JCAHO's website.