Why Report Sentinel Events and Severe Adverse Events to JCI?
Implementation resources for Joint Commission International (JCI)–accredited organizations regarding requirements related to reporting sentinel and adverse events, includes:
Standards QPS.7, QPS.8, QPS.11, GLD.1.2, and GLD.4.1 in the 6th edition Hospital (and Academic Medical Center) Standards
Joint Commission International (JCI)–accredited organizations are encouraged-but not required—to self-report sentinel events and severe adverse events. Careful evaluation of these types of patient safety events includes conducting a comprehensive analysis of the event at the system and process level, as well as developing and implementing appropriate corrective actions that may reduce the probability of similar events from occurring in the future. A thorough and credible analysis is essential to identify contributing factors and opportunities for improvement to reduce risk and prevent patient/visitor/staff harm. JCI promotes self-reporting of sentinel and severe adverse events in the interest of promoting greater patient safety and for the following more specific reasons:
Comprehensive Event Analysis Support. JCI may provide support and expertise to the hospital during the review of the submitted event analysis and proposed action plan with the Office of Quality & Safety Monitoring Program patient safety specialist.
Shared learning. During the interaction between the organization and JCI, there are often opportunities to share lessons learned from past events in a de-identified fashion. For example, if the sentinel or adverse event involves wrong-site surgery, JCI may share actions that have been effective for other organizations in redesigning a process surrounding laterality for surgical cases. JCI may also share opportunities for improving other areas based on knowledge of past events. The discussion between JCI and the organization— meant to maximize the sharing of information—is also designed to help the organization maximize patient safety.
Transparency. An accredited organization’s comfort with the self-reporting process speaks to the transparency the organization is striving for. Transparency is viewed as a critical component in the organization’s development of a culture of safety. Often defined as “the free uninhibited sharing of information,” transparency is considered the most important single attribute of a culture of safety.1 Transparency in self reporting events allows for shared learning among organizations. Reporting is essential to facilitate widespread sharing of lessons learned from incidents among many organizations.2 The sharing of information gained from analysis of incidents assists organizations to be safer places for patients.
Building a safe culture. Some United States organizations have described that engaging frontline staff in self-reporting without the fear of punitive action is an excellent shared learning process.3 For those organizations, the self-reporting process was seen as a way to emphasize to staff the importance of identifying and communicating risks and actual events.3
Please contact JCI’s Office of Quality & Safety Monitoring Program (JCIQuality@jcrinc.com) to report a sentinel or severe adverse event or if you have any questions. When reporting an event, a comprehensive root cause analysis (RCA) and action plan should be submitted to JCI for review and feedback.
Joint Commission International also provides a helpful tool for developing an event’s RCA and action plan.
Leape L, et al. Transforming healthcare: A safety imperative. Qual Saf Health Care. 2009;18(6):424–428.
Massachusetts Coalition for the Prevention of Medical Errors. When Things Go Wrong: Responding to Adverse Events. A Consensus Statement of the Harvard Hospitals. Mar 2006. Accessed Aug 11, 2014. http://www.macoalition.org/documents/respondingToAdverseEvents.pdf.
The Joint Commission. Why Organizations Self Report Sentinel Events to The Joint Commission. Jt Comm Perspect. 2014;39(8):11–12.
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