The 10 most frequently reported sentinel events for 2021: Editor's note: This article was updated Feb. 23 at 6:35 p.m. CT. Set expectations for your organization's performance that are reasonable, achievable and survey-able. EC News contains an update from the FDA recommending that healthcare providers transition away from crisis capacity conservation strategies such as decontaminating disposable respirators for reuse. The bad news is we see some slippage in end of April data with more red and yellow counties, and fewer green counties. We can make a difference on your journey to provide consistently excellent care for each and every patient. The Joint Commission has published the top 5 requirements identified most frequently as "not compliant" during surveys and reviews performed in 2020, and infection control standards made the list for many programs. Joint Commission Top 10 Findings Despite the pandemic and the year we thought would never end, we're already halfway through 2021! We suggest that their flow chart be discussed and analyzed at an environment of care meeting and used during EC or Quality rounds to verify that you have the correct signage present. The QSO memo makes it clear that hospitals and critical access hospitals have to send notice to other providers for emergency room visits and admissions, external transfers, and discharges. For example, it is not common to have a basketball hoop in a gym area and such a potential hazard is not typically going to be on a national environmental risk assessment tool. Protecting patients from harm involves more than safe treatments and procedures. View a larger depiction of the infographic here: Conventional, Contingency, and Crisis Care Standards: EC News has a thought-provoking article on implementing Conventional, Contingency and Crisis Care Standards that should be shared with your EM team and considered when you do revisions to your plan. Reduce the risk for. NPSG.15.01.01: Reduce the risk for suicide. Many settings still dont have a meter, an alarm or even a ball in the wall device to identify the correct air pressure relationship. Introduction. EP 5 was one of the new requirements added a couple of years ago which requires adherence to written policies and procedures in the care of patients at risk for suicide. Environment of Care It contains valuable information from ISMP and ECRI as to the root causes of infusion pump errors, such as bypassing the integrated software, or not integrating the pumps electronically with your medication orders in the EMR. And recently The Joint Commission Top 10 Read more Interoperability Standard Revisions Did you get a chance to read our May issue of the Patton Post? Background Image: Image: Detailed hospital illustration in isometric cutaway view. Many ambulatory and office-based surgery sites are led by a clinical staff member, so it is important to develop a relationship with someone who can offer general guidance on EC accountabilities. We presume that as standardization proceeds with their artificial intelligence scoring model, this is now the preferred placement for titration adjustment issues. The TJC change is noted in IM.02.02.07, EP 5 which discusses notifications the hospital must send to aftercare providers. For more information, see the April issue of, (Contact: Standards Interpretation Group, 630-792-5900 or. NPSG.15.02.01: Identify risks associated with home oxygen therapy such as home fires. Get more information about cookies and how you can refuse them by clicking on the learn more button below. QSA.02.08.01: The laboratory performs correlations to evaluate the results of the same test performed with different methodologies or instruments or at different locations. Find the exact resources you need to succeed in your accreditation journey. But if the tool fails to include all of the risks present in the hospitals actual environment, staff often forget to add a line and list the newfound risk unique to their hospital. You certainly would not want to be in a position of stating you have not seen the alert or have not considered the recommendations. However, with increased supplies and FDA guidance to move away from reprocessing, we wanted to highlight the last paragraph from this OSHA memo. The Joint Commission is a registered trademark of the Joint Commission enterprise. HR.02.01.03 This standard is again a challenge for many of our accredited organizations. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. TJC states that at a minimum these policies and procedures should address training and competence of staff, guidelines for reassessment, and constant monitoring patients who are at high risk for suicide. The ninth most frequently scored EP was again from NPSG.15.01.01, EP 4. As you might assume, any defects in these processes are high risk because there may be transmission of infection. If so, we have important feedback about current high focus areas we're seeing in 2021 surveys. This year the presentation format is more granular and identifies specific elements of performance where surveyors used the TJC SAFER Matrix to identify the particular finding as high risk or moderate risk. MM.06.01.01: The critical access hospital safely administers medications. Sadly, the second most frequent defect we see is a failure to take immediate action when air pressure relationships are known to be incorrect. In 2020, 809 total events were reported. Staff who are responsible for accessing clean medical equipment, devices and supplies need to do so in a manner to prevent contamination. Alternative Equipment Maintenance (AEM) Strategies: The lead article in EC News is a lengthy discussion of alternative equipment maintenance strategies. Obtain useful information in regards to patient safety, suicide prevention, infection control and many more. View them by specific areas by clicking here. The first element of performance is NPSG.15.01.01, EP 1 which requires the suicide risk assessment of the physical environment. Copyright 2023 Becker's Healthcare. See how our expertise and rigorous standards can help organizations like yours. This would be an organizational decision and the organization will be surveyed to the process approved by leadership. These are as follows: 90% Flu Vaccination Goal: Infection Control Chapter (IC.02.04.01 EP 5) Joint Commission Online is The Joint Commission's weekly newsletter and is posted every Wednesday. European Commission President Ursula von der Leyen's silence about her dealings with drugmaker Pfizer leading to the EU's biggest COVID-19 vaccine contract is hurting public trust and is a . In 2021, the most frequently reported sentinel event category was care management events with patient falls being the single largest reported harm events. Get more information about cookies and how you can refuse them by clicking on the learn more button below. This portal will provide information to reduce findings of non-compliance. Please contact us soon! This keyword logic may be helpful at your own organization to assist staff in correct identification of a standard and EP to score for an issue they see. Find evidence-based sources on preventing infections in clinical settings. The seventh most frequently scored EP is EC.02.02.01, EP 5 which requires the organization to minimize risks associated with hazardous chemicals. This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. The key to success would appear to be not letting budgets or staffing shortages get in the way of ensuring that each patient identified to be at high risk to have the required 1:1 supervision. Medical Gas Room Signage, COVID-19 Test Positivity Rates Learn about the development and implementation of standardized performance measures. We develop and implement measures for accountability and quality improvement. Rank Incidence of High Harm Percent High Harm Clinical or Environmental Association with ITL Clinical High-level disinfection and sterilization IC.02.02.01 EP02 2000 2 790 40% Clinical The Top 10 most frequently reported sentinel events in 2021 were: The summary data of sentinel event statistics covers 18,018 incidents reported from 1995 through Dec. 31, 2021. They house a variety of materials and equipment that can cause harm. Identify risks associated with home oxygen therapy such as home fires. Leave a Reply Cancel reply. The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life. The first step to make sure an organization is compliant is to properly inventory these systems to keep current with maintenance intervals. IC.02.02.01: The critical access hospital reduces the risk of infections associated with medical equipment, devices, and supplies. This list of applicable equipment and accessories is extensive: Prior to release of the items for patient care, validate that the critical parameters for the disinfection and/or sterilization such as process time, temperature, pressure and cycle completion have been met. Learn more about the communities and organizations we serve. EC 02.05.07 This standard focuses on ITM activities related to electrical infrastructure support systems, specifically: The critical nature of these systems is directly tied to the delivery of patient care. The 10 most frequently reported sentinel events for 2021: Fall 485 reported events Delay in treatment 97 Unintended retention of a foreign object 97 Wrong surgical site 85 Patient. HRM.01.02.01: The organization verifies and evaluates staff credentials. The decision on who an organization brings in to care for its patients is arguably the most important decision an organization makes. Cookie Policy. Official position of SIG Engineering on challenging standards and EPs. Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. The Joint Commission reviewed 1,197 sentinel events in 2021, with the majority of these 89% (1,068) being voluntarily self-reported by an accredited or certified entity. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the. Crisis care planning is not yet a requirement of the standards, but we have read that TJC will be revising the standards in the near future. The Joint Commission is a registered trademark of the Joint Commission enterprise. A failure could result in serious injury or the inability to safely evacuate a space during an emergency. The first CMS tag touched is A-0470 and it requires notice be sent for registration as an inpatient or emergency room patient to external providers. IC.02.01.01: The practice implements infection prevention and control plan. The number of serious patient safety incidents reported to The Joint Commission jumped in 2021, reaching the highest annual level seen since the accrediting body started publicly reporting them in 2007, according to a report shared with Becker's Feb. 22. We help you measure, assess and improve your performance. Given the detailed high-level disinfection work that staff perform for intracavitary probes this means keeping the now clean probe clean until it is used again, which may require a cover or cabinet to protect it. Top 10 Joint Commission Findings Non-Compliance Issues from 688 Hospitals (January 1, 2019 - June 30, 2019) Top 10 Joint Commission Finding for Hospitals in 2018, Including 1460 Surveys Barrier Management Symposium 2017 - Produced by The Joint Commission, ASHE, UL & FCIA Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. The Joint Commission's Top Environment of Care and Life Safety Citations: 56% for EC.02.06.01 (maintenance of a safe environment) An unsafe environment can cause harm to both patients and the staff. (Contact: Standards Interpretation Group, 630-792-5900 or online question form). During 2020, there were shortages of the previously discussed staff respirators, ventilators, and oxygen. The content changes are minimal but perhaps the breadth and scope of what surveyors will be examining may be more detailed. If you have the staff and resources and have implemented AEM already, then this article is a good opportunity to verify your program is compliant or fine tune it. The top five most challenging requirements for hospitals in 2021: 1. Learn how working with the Joint Commission benefits your organization and community. Four very important clinical issues are discussed this month including inappropriate sharing of insulin pens, improper cleaning of glucometers between patients, and sharing of lancets or lancet holders. Find evidence-based sources on preventing infections in clinical settings. The technical storage or access is strictly necessary for the legitimate purpose of enabling the use of a specific service explicitly requested by the subscriber or user, or for the sole purpose of carrying out the transmission of a communication over an electronic communications network. The Joint Commission (TJC) discussed this in their Consistent Interpretation column from their May issue of Perspectives and it is worth bringing up to you again. Top 10 High & Moderate Risk Findings for 2020: This month we will not be breaking our discussion into high or lower priorities since Perspectives has some good information about scoring practices experienced in 2020. We have followed for 15 years the press announcements about hospitals where insulin pens were shared between patients and the adverse media attention and survey attention these organizations have received. See how our expertise and rigorous standards can help organizations like yours. Elizabeth Even, MSN, RN, CEN, is associate director, Clinical Standards Interpretation Group, for The Joint Commission. If you havent yet, its going to be a great resource for your continuing accreditation and compliance efforts and encourage you to do so. View them by specific areas by clicking here. Intended Audience includes: Hospital Leaders, Facilities Managers, Clinicians andQuality Coordinator/Leaders. 46% of sentinel events led to a patients death. We develop and implement measures for accountability and quality improvement. This is a very interesting recommendation in that you have an opportunity to potentially intervene in real time to prevent patient injury. The terminology and description of the different types of respirators is sometimes confusing, so we have included here a CDC infographic that identifies the different types of equipment in use throughout the nation. The eighth most frequently scored EP was NPSG.15.01.01, EP 5. TJC's goal and mission are to ensure quality healthcare for patients, prevent harm, and improve patient advocacy. Building is shaped like the Star of Life. CMS and Joint Commission have been examining this data to determine suitability for survey.