Sentinel Event Reporting, Legal Implications & Risk Management

Introduction

A sentinel event is reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) through a root cause analysis and an action plan according to set timetables and procedures. In addition, a sentinel event can carry numerous civil and criminal implications. Through the methodical reporting and root cause analysis framework established by JCAHO, however, hospital administrators can develop highly effective risk management programs.

The Basics of Sentinel Event Reporting

A reviewable sentinel event may be self-reported or reported after notification that JCAHO is aware of the event. Self-reporting uses a computerized form in the "Continuous Compliance Tools" subsection of the "Self-Report Sentinel Event" section on the "Joint Commission Connect"™ intranet site (JCAHO, 2012, p. 13). The hospital must prepare a root cause analysis and action plan within 45 calendar days of the occurrence or awareness of the occurrence and must submit them to JCAHO within 45 calendar days of the known occurrence. If reviewability is determined more than 45 days after the known event, the hospital has 15 calendar days to submit the root cause analysis and action plan to JCAHO. If the hospital fails to submit them more than 45 calendar days after the due date, the failure may affect the hospital's accreditation (JCAHO, 2012, p. 9).

If JCAHO determines that the root cause analysis and/or action plan are unacceptable, it will consult with the hospital and grant an additional 15 calendar days to bring those documents into compliance. If the hospital still fails to submit an acceptable root cause analysis and action plan, and if JCAHO determines that the hospital did not make serious efforts to improve, accreditation may be affected (JCAHO, 2012, p. 16). If JCAHO determines that the root cause analysis and action plan are acceptable, it will notify the hospital and assign an appropriate follow-up activity that the hospital will have four months to complete (JCAHO, 2012, p. 17). The hospital may request a JCAHO review of its response in writing within at least five business days of either the self-report or of JCAHO's notification of its awareness of the reviewable sentinel event (JCAHO, 2012, p. 16).

The root cause analysis focuses on systems and processes to identify the factors causing a variation in performance. A root cause analysis moves from "special causes" — intermittent and unpredictable causes not inherent in the process or system — to "common causes," which are inherent aspects of the process or system. The analysis must be thorough, credible, and acceptable.

It is thorough if it determines all factors most directly associated with the event, analyzes the underlying systems and processes through "Why?" questions to find where redesign could reduce risk, inquires into all appropriate areas connected to the type of event, identifies the risk points and their possible contributions, and determines potential effective improvements to reduce the chance of future events — or determines that no opportunities for improvement exist.

It is credible if it involves hospital leadership and the staff most closely involved in the processes and systems being reviewed, is internally consistent, answers all obvious questions, explains all "not applicable" and "no problem" findings, and considers relevant literature.

It is acceptable if it is both thorough and credible, focuses on systems and processes rather than individuals, progresses from special causes to common causes, continuously digs deeper through progressive "Why?" questions, and provides possible changes that could reduce the likelihood of a similar event (JCAHO, 2012, pp. 10–11).

An action plan is acceptable if it identifies changes to reduce risk or provides a rationale for not adopting those changes, and — if improvements are planned — states who is responsible for implementation, when the changes will occur, and how effectiveness will be evaluated (JCAHO, 2012, p. 11).

The Legal Implications of Sentinel Events

Aside from implications for accreditation, there are numerous legal implications arising from sentinel events. Because a "sentinel event" encompasses "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" (JCAHO, 2012, p. 1) — including but not limited to deaths (including suicides), sexual abuse or assault, abduction, and serious surgical or radiological mistakes — the hospital and involved staff members may be subject to civil suit (MacCourt & Bernstein, 2009).

In conjunction with possible civil liability, and depending on the terms of applicable liability insurance, the hospital and/or staff may also be required to report sentinel events to the insurer in a timely manner (MacCourt & Bernstein, 2009). Criminal liability is also an important factor to consider. Depending on federal, state, and local laws, the hospital and involved staff members may be subject to criminal prosecution, and may additionally be required to report the incident to local authorities (MacCourt & Bernstein, 2009). Consequently, hospital policies regarding accreditation, civil law requirements, and criminal law requirements must be thoroughly enumerated and clearly communicated to all hospital staff.

Conclusion

A reviewable sentinel event may be self-reported or reported after notification that JCAHO is aware of the event. Self-reporting uses a computerized form in the "Continuous Compliance Tools" subsection of the "Self-Report Sentinel Event" section on the "Joint Commission Connect"™ intranet site (JCAHO, 2012, p. 13). The hospital must prepare a root cause analysis and action plan within 45 calendar days of the occurrence or awareness of the occurrence and must submit them to JCAHO within 45 calendar days of the known occurrence. If reviewability is determined more than 45 days after the known event, the hospital has 15 calendar days to submit the root cause analysis and action plan to JCAHO. If the hospital fails to submit them more than 45 calendar days after the due date, the failure may affect the hospital's accreditation (JCAHO, 2012, p. 9).