Hospitals given chance to choose non-sentinel event ORYX measures
Hospitals given chance to choose non-sentinel event ORYX measures
Editor’s note: Shortly before going to press, Hospital Peer Review obtained the following memorandum, sent by Joseph L. Cappiello, vice president of accreditation services at the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Health care Organizations, to quality managers at 60 hospitals. The memorandum details the Joint Com mis sion’s plan to use data collected from 13 measures under the ORYX initiative to identify sentinel events.
Sept. 30, 1999
As you may be aware, the Joint Commission’s Sentinel Event Policy encourages the self-reporting of medical errors. This letter is to alert you to a modification in the implementation of the Sentinel Event Policy that may impact your organization by virtue of your ORYX selection. It is expected that by self-reporting sentinel events, health care organizations can learn about the relative frequencies and underlying causes of sentinel events, share "lessons learned" with other health care organizations, and, as a result, reduce the risk of future sentinel event occurrences. . . .
Recently, the Joint Commission’s Board of Commissioners determined that ORYX data transmitted from a performance measurement system that meets the strict criteria for a reviewable sentinel event shall be reviewed as a self-reported sentinel event. As a result, an analysis of all active measures in the Joint Commission’s ORYX database was completed. Thirteen measures were identified as meeting the Joint Commission’s definition of a sentinel event. If appropriately measured and reported, and there are no mitigating clinical circumstances, these may well represent actual occurrences of sentinel events. . . . These measures were selected by 60 health care organizations throughout the country.
This correspondence is to inform you that your organization selected one or more of the 13 measures identified as a reviewable sentinel event measure. It is the intent of this letter to both inform you of the Joint Commission’s plans to review the 13 measures as potential sentinel events, and to inform you that you may change your measure at this time if you so choose.
If the Joint Commission becomes aware of a reviewable sentinel event through transmission of ORYX data beginning with data collected Jan. 1, 2000, the organization is required to submit to the Joint Commission its root cause analysis and action plan, or otherwise provide for Joint Commission evaluation of its response to the sentinel event under an approved protocol, within 45 calendar days of the known occurrence of the event.
If your organization chooses to select a new measure to replace the sentinel event measure, you are requested to complete the attached Measure Selection Form and fax the completed, signed form to the ORYX Information Line at (630) 792-4599 by November 15, 1999. Likewise, if you have additional questions related to ORYX or this letter, please don’t hesitate to contact the ORYX information line at (630) 792-5085 or your accreditation specialist.
Sincerely,
Joseph L. Cappiello
Vice President — Accreditation Services
Joint Commission on Accreditation of Healthcare Organizations
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