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Revisions in the Sentinel Event Policy of All Accreditation Programs

By November 6, 2019C&A Blog

Effective January 1, 2020, three definitions have been revised in the Sentinel Event Policy of all accreditation programs.  Please check and update your organizations Sentinel Event policy and procedures to reflect these changes.


This revised definition applies to ambulatory health care, behavioral health care, critical access hospital, hospital, laboratory, nursing care center, and office-based surgery: 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 in use at the time of the event; staff do not need to be present.*

Hemolytic Transfusion Reaction:

This revised definition 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.

Invasive Procedure:

This revised definition applies to all accreditation programs: Surgery or other invasive procedure* performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient.

The following non-inclusive list provides examples of events that would be considered a sentinel event:

Central line placed in wrong patient

Punch excision of incorrect mole

Computed tomography with contrast performed when not intended

Retained vaginal sponge post vaginal delivery

Retained throat packs following an ear, nose, and throat procedure

For more information see the November issue of Joint Commission’s Perspectives.

James Ballard

Author James Ballard

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