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Joint Commission releases 2017 sentinel event stats

Unintended retention of a foreign body, patient falls, and wrong-site surgery top The Joint Commission’s full list of reported sentinel events for 2017.

Every year, The Joint Commission complies a list of all the sentinel events that hospitals reported to them. Since the list only comes from self-reported data, it tends to underrepresent the real frequency of these problems. However, it’s useful in identifying trends, causes, and outcomes of adverse events. The top 10 sentinel events in 2017 were:

  1. Unintended retention of a foreign body
  2. Falls
  3. Wrong patient, wrong site, wrong procedure
  4. Suicide
  5. Delays in treatment
  6. Other unanticipated events
  7. Criminal events
  8. Medication errors
  9. Operative/postoperative complication
  10. Self-inflicted injury

The only new addition to the list since 2016 is “self-inflicted injuries,” which replaced “perinatal death/injury.” While a few hopped up or down one on the list, for the most part, there wasn’t much change.

West Virginia cities sue Joint Commission over alleged role in opioid crisis

Four West Virginia cities and towns filed a class-action lawsuit against The Joint Commission and Joint Commission Resources on November 2, claiming the accreditor “grossly misrepresented the addictive qualities of opioids” in their pain management standards. The town of Ceredo and cities of Charleston, Huntington, and Kenova claim that those standards forced hospitals to prescribe unsafe amounts of painkillers, fueling addiction and deaths in the state. [Is there any dollar amount named in the lawsuit? What is it asking for?]

“This lawsuit is a critical move toward eliminating the source of opioid addiction and holding one of the most culpable parties responsible,” said Huntington Mayor Steve Williams. “For too long, [The Joint Commission] has operated in concert with opioid producers to establish pain management guidelines that feature the use of opioids virtually without restriction. The [commission’s] standards are based on bad science, if they are based on any science at all.”

West Virginia has the highest drug overdose death rate in the nation, with 41.5 deaths per 100,000 in 2015. Huntington and Cabell County had the highest overdose fatality rate in the state last year.

The lawsuit claims that the pharmaceutical companies like Purdue Pharma (the makers of OxyContin) worked with The Joint Commission to create the pain management standards. These companies stood to gain from the overuse of their drugs, the lawsuit claims.

The Joint Commission accredits at least 10 hospitals and healthcare facilities in Charleston and Huntington, and other cities and towns are expected to join the federal lawsuit.

The Joint Commission updated its pain management standards in June to reduce over prescriptions, which will take effect on January 1. However, the lawsuit says the accreditor waited too long to make those changes.

This isn’t the first time that The Joint Commission has come under fire either. In 2016 more than 60 medical experts and nonprofit organizations signed petitions asking the commission to change its standards. Claiming they “foster dangerous pain control practices, the endpoint of which is often the inappropriate provision of opioids with disastrous adverse consequences for individuals, families, and communities.”

Sentinel Events for 2016

In the March issue of Perspectives, The Joint Commission announced that it had added 2016’s sentinel event data to its database. There were 824 sentinel events reported to The Joint Commission between January 1 and December 31, 2016. And 81% of those events were submitted voluntarily by the organization that experienced them. The most often reported events were:

  1. Unintended retention of a foreign object – 120
  2. Wrong patient, wrong site, or wrong procedure – 104
  3. Falls – 92
  4. Suicide – 87
  5. Delay in treatment – 54
  6. Other unanticipated events – 47
  7. Operative/postoperative complication – 45
  8. Medication error – 33
  9. Criminal event – 32
  10. Perinatal death/injury – 23

 

Readers should note that less than 2% of all sentinel events are reported to The Joint Commission, and these numbers can’t show the actual frequency of these events.

“In 2016 the trend for the most frequently reported sentinel events continued to be unintended retention of foreign objects, ‘wrong-patient, wrong-site, wrong procedure’ events, patient falls, patient suicides, and delays in treatment,” wrote Gerard M. Castro, PhD, MPH, Joint Commission project director, in Perspectives. “These are not new problems to health care, which indicates that organizations continue to struggle with how to prevent them.

Joint Commission publishes 2017 Survey Activity Guide

The Joint Commission just published its 2017 Survey Activity Guide, with information on how to prepare for your next survey. It also contains details on policy changes in 2017, such as the new antimicrobial stewardship program standard for hospitals, critical access hospitals, and nursing homes.

Joint Commission updates Enterprise Content Library Index

The Joint Commission Enterprise Content Library Index was updated this month with thousands of resources on hospital accreditation. The index includes articles, books, webpages, videos, webinars, podcasts, lessons, and FAQs on a myriad of topics. While much of the content is free, some of it is only available to paying Joint Commission customers.

Joint Commission releases Enterprise Content Library Index

The Joint Commission recently released its Enterprise Content Library (ECL) Index, a 177-page PDF of Joint Commission content organized by topic.

Topics include:
• Care Coordination & Transitions
• Diagnostic Imaging
• Emergency Management
• Facilities – EC & Life Safety
• Governance & Leadership
• Health IT & EHRs
• Human Resources
• Infection Control
• Laboratories

The ECL Index will be updated every quarter and the majority of its content is free. However, some items are only available to Joint Commission customers. Information can also be accessed for a fee. Click here to visit the Index.

Winners of Eisenberg patient safety and quality award announced

The National Quality Forum (NQF) and The Joint Commission today announced the 2015 winners of the John M. Eisenberg Patient Safety and Quality Award. The award, named after the former head of the Agency for Healthcare Research and Quality, recognizes those who have made great achievements in the arena of patient safety and quality.

Individual Achievement Award—Pascale Carayon, PhD, Procter & Gamble Bascom Professor in Total Quality, Department of Industrial and Systems Engineering, University of Wisconsin-Madison
Pascale Carayon was honored for her work advancing both human factors engineering concepts and methods, and the Systems Engineering Initiative for Patient Safety model. She also was recognized for mentoring new leaders in this arena at the national and international level.

Local Level Award—Mayo Clinic Hospital-Rochester, Minnesota
By engaging its staff, using a multidisciplinary team approach, identifying possible interventions, and developing an effective toolkit, the Mayo Clinic Hospital-Rochester was able to cut catheter-associated urinary tract infections rates by 70% in its facility.

National Level Award—Premier, Inc., Charlotte, North Carolina
In 2008 Premier developed the national quality improvement initiative QUEST® (Quality, Efficiency, Safety and Transparency) to help health systems reliably deliver an efficient, effective, and caring experience for every patient. In the eight years since its inception, the QUEST program has enabled easy data sharing between 350 volunteer health systems and saved 176,000 lives and more than $15 billion in healthcare costs.

Read more about the 2015 John M. Eisenberg Awards here. 

Comments open for Joint Commission inpatient diabetes care certification

The Joint Commission plans to update its Advanced Certification for Inpatient Diabetes Care program and is asking the public for input. The move is part of an effort to enhance certification programs regarding disease-specific care. The current advanced certification for diabetes care is based on the American Diabetes Association’s 2014 “Standards of Medical Care in Diabetes.”

The comment period closes on May 17. Those interested in participating are asked to read the Advanced Certification for Inpatient Diabetes Care Proposed Requirements before responding via online survey, online form, or traditional mail.

 

All 2016 National Patient Safety Goals are online

The Joint Commission has published links to all its National Patient Safety Goals (NPSG) programs for 2016. The NPSGs cover ambulatory healthcare, behavioral healthcare, critical access hospitals, home care, hospital, laboratory services, long-term care for Medicare and Medicaid, nursing care center, and office-based surgery.

Each topic is linked to the NPSG chapter plus an easy-to-read version of each chapter. Click here to see the page. 

Joint Commission seeks electronic quality measure success stories

As part of its new Pioneers in Quality portal, The Joint Commission is asking hospitals to give their stories on the electronic clinical quality measures (eCQM). Hospitals are asked to share the problems they overcame and the successes they had while implementing the eCQM and transmitting eCQM data.

Anyone interested in participating is encouraged to use The Joint Commission’s Core Measure Solution Exchange to submit their stories. Click here to get more information on the Core Measure Solution Exchange and to sign up.