Tag Archives: Sentinel Event Alert

Joint Commission Issues Sentinel Event Alert on Preventing Suicide in Healthcare Settings

The Joint Commission today issued new Sentinel Event Alert #56: Detecting and Treating Suicide Ideation in All Settings, aiming to assist healthcare organizations providing both inpatient and outpatient care with better identifying and treating individuals with suicidal ideation.

The Joint Commission indicates the rate of suicide is increasing in the United States, and is now the tenth leading cause of death. Suicide claims more lives than traffic accidents, and more than twice as many lives as homicides. At the point of care, providers often do not detect the suicidal thoughts of individuals, including children and adolescents, who eventually die by suicide, even though most of these individuals receive healthcare services in the year prior to death, usually for reasons unrelated to suicidal ideation or mental health.

Suicide events are consistently among the top 10 reported sentinel events, and, along with fall-related events, were the third most reviewed sentinel event in 2015.

The suggested actions in the Alert cover suicidal ideation detection, as well as the screening, risk assessment, safety, treatment, discharge, and follow-up care of at-risk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care.

The Alert also includes a list of Joint Commission standards relevant to suicide, and an infographic.

The new Sentinel Event Alert #56: Detecting and Treating Suicide Ideation in All Settings replaces two previous Sentinel Event Alerts on suicide, Issues #7 and #46.

Joint Commission Addresses Prevention of Unintended Retained Foreign Objects (URFOs)

In the January 2016 issue of Quick Safety, published January 26, 2016, The Joint Commission addresses strategies for preventing unintended retained foreign objects (URFOs).

The Joint Commission indicates that URFOs remain a challenge for accredited organizations, and identifies that URFOs were the most frequent sentinel event reported to its sentinel event database during 2015 (115 reported) and 2014 (112 reported). This is an increase from 2013 (102 reported), when URFOs dipped to the third most frequently reported sentinel event. URFOs were also the most frequently reported sentinel event in both 2012 and 2011. URFOs were first added to The Joint Commission’s Sentinel Event Policy in 2005.

See Joint Commission Updates Sentinel Event Statistics Through Q3 2015, URFOs Top List

To prevent URFOs, The Joint Commission recommends organizations address count process, team communication and interaction in the OR, tools and methods used during a procedure, physical environment, radiology, and reporting of the discovery of a URFO. Additional details are provided for each recommendation.

Previously, in October 2013, The Joint Commission addressed the prevention of URFOs in Sentinel Event Alert #51: Preventing Unintended Retained Foreign Objects.

More recently, in early January 2016, the Association of periOperative Registered Nurses (AORN) updated its Guideline for Prevention of Retained Surgical Items. The updated AORN guideline provides guidance to perioperative team members for prevention of retained surgical items (RSIs) in patients undergoing operative and other invasive procedures. Guidance is provided for implementing a consistent multidisciplinary approach to preventing RSIs, improving team communication, limiting distractions, standardizing protocols for surgical counts, preventing retention of device fragments, reconciling count discrepancies, and using adjunct technologies to supplement manual count procedures. The revised AORN guidelines were effective January 15, 2016.

See AORN Updates Guideline for Prevention of Retained Surgical Items

Joint Commission Updates Sentinel Event Statistics Through Q3 2015, URFOs Top List

The Joint Commission has updated its Sentinel Event statistics through Q3 2015, and published four related presentations.

Since The Joint Commission implemented the Sentinel Event database in January 1995 the organization has reviewed a total of 11,917 Sentinel Events and issued 55 Sentinel Event Alerts, the most recent being Sentinel Event Alert #55: Preventing Falls and Fall-Related Injuries in Health Care Facilities on September 28, 2015.

In 2011, The Joint Commission began presenting data for specific analytics dating back to 2004 only, including reporting source, Sentinel Event setting, and Sentinel Event outcome. Data for these analytics from 1995 to 2003 is not provided.

According to the latest statistics, since 2004 The Joint Commission has reviewed 9,376 Sentinel Events, determined 9,594 patients were impacted by these events, and identified 5,469 (57%) of the events resulted in patient death and 857 (8.9%) resulted in permanent loss of function. Since 2004, the majority of reviewed Sentinel Events (6,248, 66.7%) occurred in the hospital setting.

Links to the individual Sentinel Event presentations are included below.

Sentinel Event-related data demonstrates the need of the Joint Commission and accredited health care organizations to continue to address serious adverse events. The data also supports the importance of establishing National Patient Safety Goals (NPSGs) and focusing energies on addressing serious errors within health care organizations. By identifying causes, trends, settings and outcomes of Sentinel Events, The Joint Commission can provide critical information in the prevention of Sentinel Events to accredited health care organizations and to the public.

The Joint Commission cautions that the reporting of most Sentinel Events is voluntary and represents only a small proportion of actual events. Therefore, the data is epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Joint Commission Issues Sentinel Event Alert on Preventing Falls and Fall-Related Injuries

The Joint Commission issued a new Sentinel Event Alert on September 28, 2015 – Sentinel Event Alert #55: Preventing Falls and Fall-Related Injuries in Health Care Facilities – noting that elderly patients and those with identified risk factors are not the only patients who may fall in healthcare facilities. Any patient of any age or physical ability can be at risk for a fall due to physiological changes due to a medical condition, medications, surgery, procedures, or diagnostic testing that can leave them weakened or confused. Falls are consistently among the top 10 reported Sentinel Events.

The Alert highlights strategies to raise awareness and limit fall incidents, cites resources and references, and recommends that organizations begin by raising awareness of falls throughout the organization and establish an interdisciplinary falls prevention committee.

The Joint Commission further recommends that providers use individualized, validated assessment tools to identify patients’ risk factors and develop individualized care plans based on those risks that are specific to patients, populations, or care settings. Standardized interventions, including standardized hand-off communication and one-to-one patient education, should also be in place.

When a fall does occur, the Joint Commission recommends a post-fall huddle to discuss factors such as what happened, how it happened, and why; report, aggregate, and analyze information related to fall; and continue to reassess the patient.

The Sentinel Event Alert also includes a list of fall-related Joint Commission standards, and a preventing falls  infographic.

 

Joint Commission Issues Sentinel Event Alert on Transition to New ISO Tubing Connector Standards

On August 20, 2014, The Joint Commission published Sentinel Event Alert Issue 53: Managing Risk During Transition to New ISO Tubing Connector Standards.

According to the latest Sentinel Event Alert, “Tubing misconnections continue to cause severe patient injury and death, since tubes with different functions can easily be connected using luer connectors, or connections can be “rigged” (constructed) using adapters, tubing or catheters. This is why new ISO (International Organization for Standardization) tubing connector standards are being developed for manufacturers.”

The Sentinel Event Alert addresses the phased implementation of the redesigned tubing connectors resulting from the new ISO connector standards, urges healthcare organizations to be vigilant and begin planning for the upcoming period of transition, which will introduce changes and new risks into the health care environment, and presents examples of adverse events related to tubing misconnections.

These suggested actions update the recommendations in The Joint Commission’s 2006 Sentinel Event Alert Issue 36: Tubing Misconnections—A Persistent and Potentially Deadly Occurrence.

Resources are also identified in the new Sentinel Event Alert, including:

The Sentinel Event Alert also includes a list of Joint Commission standards related to the use of tubing, and an infographic.