The Joint Commission adopted the formal Sentinel Event Policy in 1996 “to help hospitals that experience serious adverse events improve safety and learn from those sentinel events.” TJC goes on to define sentinel events as “a Patient Safety Event that reaches a patient and results in…death, permanent harm, or severe temporary harm and intervention required to sustain life.”The Joint Commission has recently announced revised definitions of three terms, in an effort to better clarify and identify sentinel events. The revisions are effective on January 1, 2020.
The three updated terms are:
- Fire
- Hemolytic Transfusion Reaction
- Invasive Procedure (as referred to in relation to wrong-site procedures and unintended retentions).
Let’s look closer at the current and revised definitions of these three events and some examples of what would and would not be considered a sentinel event under these definitions.
FIRE
The current definition is fire, flame or unanticipated smoke, heat, or flashes occurring during an episode of patient care-was intended to refer to fires in the OR.
Concerns with this definition include:
- When the Office of Quality and Patient Safety (OQPS) reviewed the reported events, it was clear that healthcare organizations were experiencing fires or unanticipated smoke, heat, or flashes “in other care locations causing confusion on whether these events should be considered ‘sentinel.’”
- Another area of concern is that the current definition did not include clinical equipment that malfunctioned when a caregiver was not present in the room.
- The definition did not define the full scope of the home health encounter (which is the entire length of services ordered by a physician). Given the safety risks that exist with home oxygen therapy, this is a significant concern.
The new definition, which applies to ambulatory health care, behavioral healthcare, critical access hospital, laboratory, nursing center and office-based surgery is:
Fire, flame or unanticipated smoke, heat, or flashes occurring during direct patient care caused by equipment operated and used by the organization. To be considered a sentinel event, equipment must be used at the time of the event and staff do not need to be present.”
The new definition of ‘Fire that pertains to home care setting is:
Fire, flame or unanticipated smoke, heat, or flashes occurring during an episode of patient care. This includes any fire in the patient’s home that is related to the care or treatment ordered by a provider, including home oxygen administration, as part of the home care services, regardless of whether a home care staff member was present.
Under the new definition of ‘Fire’ the following would and would NOT be considered a sentinel event. These lists are not inclusive.
Would be considered a Sentinel Event
- While on the premises of an organization, a patient on oxygen catches fire while smoking.
- While a patient is wearing physician ordered oxygen therapy, a cooking related fire occurs.
- A fire in the home caused by a lit candle while oxygen is in use.
Would NOT be considered a Sentinel Event
- Spark, smoke or flame from an electronic device that is brought to the facility by the patient for his or her own use such as a tablet, phone, or game system.
- Smoke, fire, or flame at a nursing station due to burnt popcorn or the malfunction of a microwave.
- A socket spark resulting from equipment plugged into an outlet. (NOTE: If the socket spark results in harm to a patient it is reported as a sentinel event).
- A fire in the home while cooking or caused by malfunctioning personal equipment, home appliances, audiovisual equipment, or home ventilation systems while the patient is under home care services.
HEMOLYTIC TRANSFUSION REACTION
The current definition of hemolytic transfusion reaction involves the administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups). This definition only focuses on ‘hemolytic’ reactions and doesn’t speak to other significant adverse transfusion events.
Here is the revised definition which applies to ALL accreditation programs:
Administration of blood or blood products having unintended ABO and non-ABO (Rh, Duffy, Kell, Lewis and other clinically important blood groups) incompatibilities, hemolytic transfusion reactions or transfusions resulting in severe temporary harm, permanent harm or death.
Under the new definition of ‘Hemolytic Transfusion Reaction,’ the following would and would NOT be considered a sentinel event. These lists are not inclusive.
Would be considered a Sentinel Event
- During pre-transfusion testing, lab staff did not check if a patient had known antibodies previously and subsequently did not cross-match the patient with blood products that were negative for the corresponding antigen, resulting in a delayed hemolytic transfusion reaction.
- The patient was transfused with platelets and suffered a reaction. Platelets were found to be contaminated with gram-negative bacteria and patient transferred to the ICU for additional treatment.
Would NOT be considered a Sentinel Event
- Blood products stored in refrigerators that were not continuously monitored for temperatures, nor was there documentation any temperatures were recorded, and blood products released for transfusion by lab staff and reached the patient but did not cause harm.
- The patient was transfused O+ blood under the hospital’s emergency release policy and was subsequently identified that the patient was typed O-.
INVASIVE PROCEDURE
The current Sentinel Event Policy does not define “invasive procedure,” creating much confusion and variation in reporting. References to invasive procedures are elaborated on in two areas:
- “Invasive procedures, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure.”
- “Unintended retention of a foreign object in a patient after an invasive procedure including surgery.”
Below, the revised definition applies to all accreditation programs:
Surgery or other invasive procedures performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for the patient.
Under the new definition of ‘Invasive Procedure,’ the following would and would NOT be considered a sentinel event. These lists are not inclusive.
Would be considered a Sentinel Event
- Central line placed in the wrong patient.
- Punch excision of incorrect mole.
- Computed tomography with contrast performed with not intended.
- Retained vaginal sponge post vaginal delivery.
- Retained throat packs following ear, nose and throat procedure.
Would NOT be considered a Sentinel Event
- An X-ray performed on incorrect site.
- Venipuncture on the wrong site or wrong person.
- Retained phlebotomy tourniquet left on arm and discovered later in the day with no harm to the patient.
In summary, keep in mind these changes for the new year when reporting sentinel events to The Joint Commission; remembering that all incidents should be reviewed and addressed by your facility.
More information can be obtained by contacting Erin Lawer, MS, CPPS, human factors engineer, at the Office of Quality and Patient Safety.
Reference:
The Joint Commission Perspectives, November 2019, Volume 39, Issue 11