The Joint Commission on Accreditation of Health Care Organizations (JCAHO) reporting of Sentinel Events



The Joint Commission on Accreditation of Health Care Organizations (JCAHO) reporting of Sentinel Events

Introduction

JCAHO is a organization began in 1951 as an oversight body to monitor quality of care in American hospitals and has extended its range to cover ambulatory care, health maintenance organizations, and the like, although as yet not significantly to public health agencies. It organized a sentinel event and the report is based on the reporting of this event.

Discussion

Ninety-eight thousand people die in America's hospitals each year from medical errors (Krouwer 2006).' This statistic has caused the entire healthcare industry and the government to make patient safety a priority. In addition, various organizations have begun to develop methods of investigation and analysis of errors that occur in healthcare facilities. The purpose of JCAHO's Sentinel Event Policy is to prevent the recurrence of sentinel events by assisting the healthcare organization in identifying the root causes of such events and designing a plan that will prevent future occurrences of similar errors (Haugh 2000). The centralized database will increase visibility. In other words, managers will be able to identify the drivers of the errors and take the necessary actions to improve the quality of care given to the patients. However, the database also serves a business function; simply stated, it saves money. A centralized data system, with automated reporting, will eliminate the need to collate and input data each time a need arises for a report. For instance, reports for the Transfusion Committee, JCAHO, California Department of Health Services, Food and Drug Administration (FDA) etc. will be readily available, which will minimize the last-minute frenzy of data gathering.

The establishment of regulatory organizations such as JCAHO has allowed health centers to report medical errors without subjecting themselves to punitive consequences. More importantly, hospitals have been given the opportunity to learn how to prevent medical errors by working with such regulatory bodies. However new methods should be developed to prevent more serious medical errors such as medication mistakes, wrong site surgeries and transfusion errors. The very definition of TQM is not subject consensus and it has evolved over the international debate on this issue. In countries we studied, the iatrogenesis is not managed as a separate entity but part of a broader risk management for events undesirable. The growing interest in the consideration and management of events undesirable, is ...