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The Joint Commission (TJC) refers to never events as “sentinel events” and since 1995 has been recommending that hospitals report them. Reporting is voluntary and currently there are 26 states that report, as well as the District of Columbia.  Many individual healthcare facilities have their own policies in place requiring the reporting of sentinel events to TJC. Once an event is reported, a root cause analysis (RCA) must be conducted. Based on the RCA, facilities may formulate an action plan to improve patient safety and reduce the chance of the same event happening again. TJC mandates the RCA and action plan once a sentinel event has been reported, in order for the facility to maintain its accreditation.

Sentinel event policy and procedures developed by TJC can be found here.

This month’s civil topic is Serious Reportable Events (“never events”). Topics covered are:

  • “Never event” defined (6/2/14)
  • Reporting Requirements (6/9/14)
  • Finding the root of the problem (6/16/14)
  • Legal implications (6/23/14)

Note: To see all posts in this topic, click here.



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