Kentucky Injury Law Blog

Kentucky medical malpractice attorneys: Do you request sentinel event and peer review information in all your medical malpractice cases? You should.

All hospitals eligible for federal funding are accredited by the Joint Commission on Accreditation of Healthcare Organizations (the “JCAHO”). As part of its accreditation survey, the JCAHO reviews its members’ processes for identifying, reporting and responding to “sentinel events”. The purpose of these guidelines is to improve patient outcomes and avoid malpractice resulting in serious personal injury or wrongful death.

In 1996, the JCAHO promulgated “Sentinel Event Policy and Procedures”. They state in part:

I. Sentinel Events
In support of its mission to improve the quality of health care provided to the public, the Joint Commission includes the review of organizations’ activities in response to sentinel events in its accreditation process . . .

◆ A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury or loss of limb or function.
◆ Such events are called “sentinel” because they signal the need for immediate investigation and response”

II. Goals of the Policy

“The goals of the policy are four-fold:
◆ To have a positive impact in improving patient care.
◆ To focus the attention of an organization that has experienced a sentinel event on understanding the causes that underlie the event, and on making changes in the organization’s systems and processes to reduce the probability of such an event in the future.
◆ To increase the general knowledge about sentinel events, their causes, and strategies for prevention.
◆ To maintain the confidence of the public in the accreditation process”

As part of the sentinel event policy, the JCAHO requires health care organizations to perform a “root cause analysis” when a sentinel event occurs, and to use “the information from the data analysis to identify changes that will improve performance or reduce the risk of sentinel events.” To maintain JCAHO accreditation, healthcare organizations must also “ensure that the processes for identifying and managing sentinel events are defined and implemented.”

Click here for a sample Motion to Compel Production of Sentinel Event and Peer Review Documents