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JC Accreditation Watch policy changes

From the December 17, 1997 issue

Changes in the JC Accreditation Watch policy are just around the corner. Beginning in April, 1998, JC will be increasing pressure on all health care organizations to self-report sentinel events. JC defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof." This includes "near misses" which carry a significant chance of serious outcome with recurrence.

In the recent decision by the JC Board, organizations are not required to report sentinel events; however, voluntary disclosure is encouraged through the promise of less severe ramifications. If an organization reports a sentinel event to JC within 5 business days of the event (or its discovery), the organization will not automatically be placed on Accreditation Watch. Rather, the organization will be given the opportunity to perform a "root cause analysis" within 30 days and submit it to JC for approval. If accepted, the organization will not be placed on Accreditation Watch. If a routine inquiry is made to JC, the organization's accreditation status will be reported without making reference to the sentinel event. If JC learns of a sentinel event that was not self-reported, such as through the media or during scheduled surveys, it will automatically place the organization on Accreditation Watch and require a "root cause analysis" of the event within 30 days. Not only is an on-site visit from JC probable, the organization's Accreditation Watch status will be publicly disclosed.

The required "root cause analysis" focuses primarily on systems and processes--why an event occurred. An acceptable analysis must be thorough, progressing from identification of special causes to common causes. Once the "root" of the problem is identified, an action plan and measurement strategy must be implemented. In order for the analysis to be credible, it must include those closest to the process being reviewed, organizational leaders and an evaluation of relevant literature. JC strongly encourages organizations to use its suggested format, a "Framework for Root Cause Analysis."

As of October, 1997, JC has reviewed 171 sentinel events under the Accreditation Watch program. The most frequently occurring sentinel events were medication errors. Of the 36 medication errors reviewed, 33 deaths occurred. One third of these events involved inadvertent intravenous injection of potassium chloride concentrate.

We invite healthcare organizations interested in having a review of their medication use processes to contact us. The review will determine areas of risk and make recommendations for preventing medication errors. In addition, we are available to assist organizations involved in medication error sentinel events. Through our expertise in system analysis and JC's required format for a "root cause analysis," we can help organizations identify system failures and recommend actions most likely to prevent errors from recurring.

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