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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.

How many will adopt the new CDC opioid guidelines?

After several months of debate, the Centers for Disease Control and Prevention (CDC) have finally published its Guideline for Prescribing Opioids for Chronic Pain on March 15. The agency’s recommendations are aimed towards primary care physicians, since family physicians alone account for 15.3 million opioid prescriptions annually. Currently, 44 Americans overdose and die each day after abusing prescription painkillers and the CDC hopes its recommendations can noticeably reduce the use of opioids in pain care.

However, the Guideline for Prescribing Opioids for Chronic Pain are voluntary and some question how many in the healthcare sector will adopt them.  Several healthcare professionals and patient groups protested the guidelines after their first draft was unveiled for comment, claiming they were too restrictive on pain care. The outcry was enough that the CDC had to organize an extra review process for the guidelines back in January.

Now it’s up to healthcare facilities, including those who protested the guidelines, to decide if they will follow the CDC’s recommendations and to what extent.  The guidelines consist of 12 recommendations total, including:

  1. Using non-pharmacologic and non-opioid therapy for chronic pain whenever possible.
  2. Establishing treatment goals before starting long-term opioid therapy. Physicians should only continue to prescribe opioids if there is “clinically meaningful improvement” that outweighs safety risks.
  3. Discussing the risks and benefits of opioids with patients before prescribing them.
  4. Using short-acting opioids instead of extended-release, long-acting drugs to treat chronic pain.
  5. Prescribing opioids in their lowest effective dosage.
  6. Using short-term opioid treatments instead of long-term treatments for acute pain care. Usually three days’ worth of opioids will be enough, though up to seven days is sometimes permissible.
  7. Patients should be evaluated within one to four weeks of beginning opioid therapy for chronic pain and be reevaluated at once every three months afterwards to assess the pros and cons of continued treatment.

Click here to read The Joint Commission’s “Facts about Pain Management” page and view its Sentinel Event Alert 49, dealing with safe use of opioids in hospitals.

 

Updated disease-specific care review process guide released

The Joint Commission has released an updated version of its Organization Review Process Guide for Disease Specific Care Certification. The update includes information on the new Advanced Certification for Total Hip and Total Knee Replacement program.

The updated information went into effect on March 1.