The new definition will state, “Fall event – Fall resulting in any of the following: any fracture surgery, casting, or traction required consult/management or comfort care for a neurological (for example, skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib fracture, small liver laceration) injury or a patient with coagulopathy who receives blood products as a result of the fall death or permanent harm as a result of injuries sustained from the fall (not from physiologic events causing the fall). This new definition will be more closely aligned with established guidelines from the National Database of Nursing Quality Indicators™ and the National Quality Forum.

Root cause analysis, focusing on systems and processes, is one form of comprehensive systematic analysis however, hospitals may use other methods or tools as well.The Joint Commission will be defining fall events in their Sentinel Event Policy starting Januto help address the need for more preventive fall measures. In addition, TJC expects hospitals to complete a “comprehensive systematic analysis” of sentinel events. Reviewing and Responding to Sentinel Events: Consistent with the more narrow definition of sentinel event, the Policy now states that all sentinel events must be reviewed by the hospital, and all sentinel events are subject to review by TJC.A similar clarification was added to the existing sentinel event regarding elopement. TJC clarified that such an incident qualifies as a sentinel event even when the suicide occurs following discharge from the hospital’s emergency department. For example, the suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge was previously recognized as a sentinel event.

Fine-Tuning of Some Sentinel Events: The Policy fine-tuned some existing sentinel events.The other relates to intrapartum maternal death that is related to the birth process, or severe maternal morbidity. One of the new sentinel events relates to fire, flame, or unanticipated smoke, heat, or flashes during patient care. New Sentinel Events: TJC added two new sentinel events.In most cases, definitions under state law will not exactly match the TJC definition, so hospital staff should use care to avoid confusion between state legal definitions and the TJC meaning, particularly when analyzing whether an adverse event must be reported to a state regulatory agency. It is important to note, however, that the term “adverse event” also exists separately under statutes and regulations in many states. Additional Categories of PSEs: The term PSE includes additional, newly-recognized categories, such as adverse events, no-harm events, close calls, and hazardous conditions.The Policy explains that sentinel events are now one category of PSE. Note that PSE includes near misses as well as actual injuries, as discussed further, below. However, it does seek to improve patient care by reviewing and responding to Sentinel Events as set forth by The Joint Commission (TJC) Sentinel Event policy.

Such an event could be the result of a defective system or process design, a system breakdown, equipment failure, human error, or something else.

New Broad-Based Definition of Patient Safety Event (PSE): The Policy now includes the broad-based term “patient safety event,” which means an incident or condition that could have resulted or did result in harm to a patient.

Now, near misses are no longer considered sentinel events. That meant “near misses” were included as sentinel events, although near misses were not considered “reviewable” by TJC. Previously, the definition included unexpected occurrences involving injury or the risk of injury.

More Narrow Definition of Sentinel Event: The definition of “sentinel event” has been narrowed.

Changes include the following, among others:

Sentinel events joint commission policy