Joint Commission Sentinel Events, HHS Office of Civil Rights Action, and AHA 2023 Outlook: Healthcare Risk Roundup

Joint Commission Sentinel Event Data & Policy Changes

The Joint Commission has released its Sentinel Event data for 2022 Q1 and Q2. The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those events. While sentinel event identification and reporting began for events involving patients, definitions expanded to include staff, vendors and visitors in the past decade.

In addition, effective July 1, 2021, The Joint Commission revised the definitions related to rape, assault, and homicide in its Sentinel Event Policy for all accreditation programs. The revised definition differentiates between sexual abuse/assault, physical assault and homicide.

Over the last five years, the most frequently reviewed sentinel events were:

  1. Falls
  2. Unintended Retention of a Foreign Object (URFO)
  3. Wrong Surgery (wrong site, wrong procedure, wrong patient, wrong implant)
  4. Suicide
  5. Delay in Treatment

HHS Office for Civil Rights Takes Action to Ensure Effective Communication for Those Who Are Deaf or Hard of Hearing

The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services has entered into a Voluntary Resolution Agreement with Catholic Health Initiatives (CHI) St. Vincent Hot Springs to ensure effective communication with individuals who are deaf or hard of hearing. CHI St. Vincent Hot Springs is a faith-based, not-for-profit hospital, with more than 280 licensed beds, serving the healthcare needs of Hot Springs, Arkansas, and surrounding communities.

The agreement resolves a complaint filed with OCR by an individual who alleged that CHI St. Vincent Hot Springs discriminated against her based on her disabilities when it failed to provide her with appropriate auxiliary aids to ensure effective communication during her visit in 2019. You can read the full agreement here.

AHA 2023 Environmental Scan Results

The American Hospital Association recently released its 2023 environmental scan. This scan “provides a snapshot of past and present trends on important issues that form the foundational pillars of the AHA strategic plan,” according to AHA.

The COVID-19 pandemic took a toll on health care across the world, from all perspectives: patients, providers and health care organizations. The pandemic’s effects are evident in the analysis of the past, current and future state of health care in areas such as patient safety and quality, financial challenges and staffing shortages.

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