TJC Releases Compliance and Sentinel Event Stats for First Half of 2018

By John Palmer

Hospitals apparently have been slow to grasp the message that certain accreditation standards need to be followed to protect patient safety, and The Joint Commission has taken note. In what has become a semiannual tradition, the accreditor has released the list of standards that healthcare organizations are having the most trouble complying with.

The latest list, published in the September issue of Perspectives, shows the standards scored most frequently as “not compliant” during Joint Commission accreditation surveys and certification reviews from January 1 through June 30, 2018.

The Joint Commission regularly collects standards compliance data to identify areas that present the greatest challenges to accredited organizations and certified programs. The information also helps the agency recognize trends and tailor education around challenging standards.

The latest statistics laid out the top 10 most frequently cited requirements for each of the following accreditation and certification programs:

  • Ambulatory healthcare accreditation
  • Behavioral healthcare accreditation
  • Critical access hospital accreditation
  • Disease-specific care certification
  • Healthcare staffing services certification
  • Homecare accreditation
  • Hospital accreditation
  • Laboratory and point-of-care testing accreditation
  • Nursing care center accreditation
  • Office-based surgery practice accreditation
  • Palliative care certification
  • Perinatal care certification

According to The Joint Commission, the following are the standards for which the most hospitals received Requirements for Improvement, or RFIs, in the first half of the year:

  • 03.01.10 (63% of hospitals): Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
  • 03.01.03 (63%): The organization has a plan for care, treatment, or services that reflects the assessed needs, strengths, preferences, and goals of the individual served.
  • 02.05.01 (82%): The critical access hospital manages risks associated with its utility systems.
  • 1 (8%): The healthcare services staffing firm confirms that a person’s qualifications are consistent with his or her assignments.
  • 01.03.01 (48%): The homecare accreditation organization plans the patient’s care.
  • 02.01.35 (88%): The hospital provides and maintains systems for extinguishing fires.
  • 01.06.01 (49%): Laboratory staff are competent to perform their responsibilities.
  • 02.01.04 (44%): The organization permits licensed independent practitioners to provide care, treatment, and services.
  • 02.02.01 (79%): The office-based surgery center practice reduces the risk of infections associated with medical equipment, devices, and supplies.
  • 6 (31%): Palliative care program leaders are responsible for selecting, orienting, educating, and retaining staff.
  • 2 (47%): The program maintains complete and accurate medical records.

Sentinel event statistics

In addition to information surrounding standards noncompliance, The Joint Commission also released its list of the top 10 frequently reported sentinel events for the first half of 2018.

According to the accreditor, the formal sentinel event policy was formed in 1996 to help hospitals that experience serious adverse events improve safety and learn from those events. Careful investigation and analysis of patient safety events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm. The sentinel event policy explains how The Joint Commission partners with healthcare organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.

A sentinel event is a patient safety event that reaches a patient and results in death, permanent harm, or severe temporary harm and the need for life-sustaining intervention. Such events are called “sentinel” because they signal the need for immediate investigation and response. Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission.

The latest list comes from reviewed reports of sentinel events and includes de-identified information about them in The Joint Commission’s Sentinel Event Database. The Database includes information collected and analyzed from the review of sentinel events and comprehensive systematic analyses, such as root cause analysis. The Joint Commission tracks aggregate information, including causes and outcomes of sentinel events, to provide critical information that may help guide local efforts to mitigate future risk.

The top 10 frequently reported sentinel events of 2018 are as follows:

  • Falls: 65
  • Unintended retention of a foreign body: 61
  • Unassigned (category unassigned at the time of the report): 55
  • Wrong-site surgery: 45
  • Other unanticipated event (includes asphyxiation, burns, choking on food, drowning, and being found unresponsive): 29
  • Suicide: 26
  • Delay in treatment: 25
  • Medication error: 17
  • Criminal event: 16
  • Perinatal death/injury: 11

Historically, these events from 2005 through the first six months of 2018 led to the following outcomes affecting 11,612 total patients:

  • Death: 5,942 patients impacted or 51.2% of the total
  • Unexpected additional care: 2,963 or 25.5%
  • Permanent loss of function: 854 or 7.4%
  • Severe temporary harm: 736 or 6.3%
  • Other/unknown/unassigned: 591 or 5.1%
  • Psychological impact: 362 or 3.1%
  • Permanent harm: 164 or 1.4%

The Joint Commission said it reviewed a total of 398 sentinel events during the first six months of 2018. A majority of these (90%, or 360) were voluntarily self-reported to The Joint Commission by an accredited or certified entity. Of the 38 non-self-reported sentinel events, 35 were reported by patients (or their families) or employees (current or former) of the organization, or they were uncovered through the patient safety reporting process. The media accounted for the remaining three non-self-reported sentinel events.

The Joint Commission observed that many of the reported events are quite typical of past lists. “The trend for the most frequently reported sentinel events remains generally unchanged,” noted Gerard M. Castro, PhD, MPH, The Joint Commission’s project director of patient safety initiatives. “Organizations should continue their work toward minimizing risks associated with these types of events, but also strengthen systems and processes that keep patients safe, such as reporting and learning from close calls, teamwork, and improving safety culture.”

Unintended retention of a foreign body, patient falls, and wrong-site surgery topped the full list of reported sentinel events for 2017. The top 10 sentinel events in that year were the following:

  • Unintended retention of a foreign body
  • Falls
  • Wrong patient, wrong site, wrong procedure
  • Suicide
  • Delays in treatment
  • Other unanticipated events
  • Criminal events
  • Medication errors
  • Operative/postoperative complication
  • Self-inflicted injury

While a few events inched up or down on the list, for the most part, there wasn’t much change from 2016. In that year, the most frequently reported events were the following:

  • Unintended retention of a foreign object
  • Wrong patient, wrong site, or wrong procedure
  • Falls
  • Suicide
  • Delay in treatment
  • Other unanticipated events
  • Operative/postoperative complication
  • Medication error
  • Criminal event
  • Perinatal death/injury

Hard at work

The Joint Commission has been busy over the last 18 months issuing several key sentinel alerts.

In March 2017, The Joint Commission issued Sentinel Event Alert #57, which replaced a previous alert issued in 2009. This new alert outlined actions leaders should take within their organizations to build trust, accountability, an eye for safety hazards, stronger systems, and better means of assessment.

First on the list of actions is ensuring that the adverse-event reporting process is neither opaque nor focused solely on doling out punishments. This nonpunitive approach can increase error reporting, giving organizations more data points to analyze in the never-ending search for weak spots to be patched.

The alert outlined 11 recommended actions and related resources for organizations to root out any intimidating behaviors that might discourage workers from reporting problems, and it encourages organizations to give special recognition to those who spot and report unsafe conditions. The document urges leaders to quantify the health of their safety culture and track it over time.

After an acknowledgement that suicide is the 10th leading cause of death, claiming more lives than traffic accidents and over twice as many as homicides, The Joint Commission issued Sentinel Alert #56: Detecting and treating suicide ideation in all settings in February 2016 as a way of bringing attention to the problem.

Further, surveyors were ordered to start placing more emphasis on the prevention of suicides in hospitals, and as of March 1, 2016 they did so, especially concentrating on the assessment of potential ligature (hanging) injuries, suicide risks, and self-harm monitoring. Extra focus was placed on psychiatric hospitals and inpatient psychiatric patient areas in general hospitals.

As a result of this specific scrutiny, an expert panel in 2017 issued 13 recommendations for hospitals to help them create a safer environment that removes ligature and suicide risks from inpatient acute and psychiatric units.

Tips for reducing violations

Some of the most common standard violations can be eliminated with simple solutions, including the following:

Be seen. Sometimes the best thing that hospital safety officials and facility managers can do to avoid some of the most common violations is to get out of their offices and walk around. The key is to identify risks proactively, look for deficiencies, and take steps to fix them. Your facility is not perfect, and there will always be problems to find.

Increased vigilance. The most seasoned hospital coordinators say the key to their success is recognizing that they can’t do the job alone. Do you have a system in place where anyone can report a safety risk? Enlist staff so you can get multiple sets of eyes out there watching for safety violations. What do they see while they’re walking around your facility? You want to know so you can analyze and correct the issues.

Exercise some common sense. Some of the most common citations are for violations related to fire doors and smoke barriers, ducts, and blocked egress points. These are things that can be easily avoided with a quick tour through the facility. Is there a cart blocking an exit door? Move it. Does a physician’s office have a fish tank with an air tube running into the ceiling tiles to tie into the hospital’s air system? It’s happened before—and it’s a major hazard, as it creates a hole through which smoke can penetrate.

Collect data. And do something with it. You shouldn’t wait until a surveyor finds something wrong to start fixing the problem. The well-prepared facilities know what their biggest problems are—and they make a plan to fix them. If the surveyors see you being proactive, they are more likely to give you a break, in the form of a categorical waiver. Do a risk assessment every year—ideally, every department should conduct its own—and use it to make a plan to fix the problems, whether it be the fire doors that won’t close right, the copiers in front of the oxygen shutoff valves at the nurses’ station, or yes, even Dr. Pesci’s fish tank.

Document and have a paper trail. You may say that you have a plan in place to fix whatever problems your facility has, but that means nothing if the surveyors can’t consult the plan for themselves. Write it down, and make sure there is a clear paper trail. For your reference, take good notes at all meetings and training sessions; have a written record of all hazard assessments, inspections, and any plans of action that are taken. Better yet, make sure everyone else is doing this as well and keeping the results in binders. If you can’t lead the surveyor to the records, you will have problems.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at