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Sentinel Event Definitions Change:

By November 12, 2019On the Radar

Effective January 1, 2020 the Joint Commission changes to some Sentinel Event definitions will go into effect.  This means that required reporting will change in association to the new definitions.  The report released indicating these changes provides insight into the current definition, new definition and rationale for making the changes.

Definition Changes apply to All Accreditation programs:

Fire

The revised definition 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 in use at the time of the event; staff do not need to be present”.

The following is a list of a few examples of events that would be considered a sentinel event:

  • Patient, on oxygen, catches fire while smoking on premises of an organization.
  • A cooking-related fire while the patient is wearing physician-ordered oxygen therapy.
  • A fire in the home caused by a lit candle while oxygen is in use.

Hemolytic Transfusion Reaction

This revised definition is: “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”.

The following is list a list of a few examples of events that would be considered a sentinel event:

  • During pretransfusion testing, laboratory staff did not check if a patient had known antibodies previously, and subsequently did not crossmatch the patient with blood products that were negative for the corresponding antigen. This resulted in a delayed hemolytic transfusion reaction.
  • Patient was transfused with platelets and suffered a reaction. Platelets were found to be contaminated with gram-negative bacteria, and patient was transferred to the intensive care unit for additional treatment.

Invasive Procedure

This revised definition is: “Surgery or other invasive procedure* performed at the wrong site, on the wrong patient, or that is the wrong (unintended) procedure for a patient”.

Invasive procedure is defined as a procedure in which skin or mucous membranes and/or connective tissue are incised or punctured; an instrument is introduced through a natural body orifice; or foreign material is inserted into the body for diagnostic or treatment-related purposes. Examples of invasive procedures include central line and chest tube insertions, biopsies and excisions, and all percutaneous procedures (for example, cardiac, electrophysiology, interventional radiology). Exclusions include venipuncture, which is defined as collection of blood from a vein.

The following is a list of a few 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

We recommend that all organizations review their current Sentinel Event policy and reporting processes to ensure that these new definitions are applied across the organization.  For more details, please review the Joint Commission Perspectives for November 2019.

James Ballard

Author James Ballard

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