Joint Commission’s Rewritten Sentinel Events Policy Now in Effect

Changes include the following, among others:

• More Narrow Definition of Sentinel Event: The definition of “sentinel event” has been narrowed. Previously, the definition included unexpected occurrences involving injury or the risk of injury. That meant “near misses” were included as sentinel events, although near misses were not considered “reviewable” by TJC. Now, near misses are no longer considered sentinel events.

• New Broad-Based Definition of Patient Safety Event (PSE): The Policy now includes the broad-based term “patient safety event,” which means an incident or condition that could have resulted or did result in harm to a patient. Such an event could be the result of a defective system or process design, a system breakdown, equipment failure, human error, or something else. Note that PSE includes near misses as well as actual injuries, as discussed further, below. The Policy explains that sentinel events are now one category of PSE.
• Additional Categories of PSEs: The term PSE includes additional, newly-recognized categories, such as adverse events, no-harm events, close calls, and hazardous conditions. It is important to note, however, that the term “adverse event” also exists separately under statutes and regulations in many states. In most cases, definitions under state law will not exactly match the TJC definition, so hospital staff should use care to avoid confusion between state legal definitions and the TJC meaning, particularly when analyzing whether an adverse event must be reported to a state regulatory agency.
• New Sentinel Events: TJC added two new sentinel events. One of the new sentinel events relates to fire, flame, or unanticipated smoke, heat, or flashes during patient care. The other relates to intrapartum maternal death that is related to the birth process, or severe maternal morbidity.
• Fine-Tuning of Some Sentinel Events: The Policy fine-tuned some existing sentinel events. For example, the suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge was previously recognized as a sentinel event. TJC clarified that such an incident qualifies as a sentinel event even when the suicide occurs following discharge from the hospital’s emergency department. A similar clarification was added to the existing sentinel event regarding elopement.
• Reviewing and Responding to Sentinel Events: Consistent with the more narrow definition of sentinel event, the Policy now states that all sentinel events must be reviewed by the hospital, and all sentinel events are subject to review by TJC. In addition, TJC expects hospitals to complete a “comprehensive systematic analysis” of sentinel events. Root cause analysis, focusing on systems and processes, is one form of comprehensive systematic analysis; however, hospitals may use other methods or tools as well.