sentinel events policy - Allied Academies

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71
AHCMJ, Volume 1, 2005
THE JOINT COMMISSION ON
ACCREDITATION OF HEALTH CARE
ORGANIZATIONS’ SENTINEL
EVENTS POLICY
Anita Hazelwood, University of Louisiana at Lafayette
Ellen Cook, University of Louisiana at Lafayette
Sarah Hazelwood, University of Louisiana at Lafayette
ABSTRACT
This article looks at the Joint Commission on Accreditation of
Healthcare Organizations’ (JCAHO) sentinel event policy which is designed
to improve the quality of health care in the United States. A brief history of
the JCAHO is included as well as a history of “incident reporting” in
general. A discussion of the background of medical errors including
information from the Institute on Medicine’s landmark report is the basis for
the increasing emphasis on medical errors and the sentinel events policy is
one of the tools used in health care organizations to combat medical errors.
A sentinel event is defined by the JCAHO as “an unexpected occurrence
involving death or serious physical or psychological injury, or the risk
thereof”. Following the identification of a sentinel event, a root cause
analysis must be completed which is a process for identifying the processes
or problems that resulted in an adverse event or incident. Identification and
reporting of sentinel events with the subsequent root cause analyses allows
organizations to implement guidelines and policies to reduce the numbers of
adverse effects occurring in hospitals and other health care facilities.
The reporting of sentinel events to the JCAHO provides the data for
the sentinel event database which provides data that can be used in the

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AHCMJ, Volume 1, 2005
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