Accountability-taking responsibility for your actions-is a simple idea. But it's not so simple to fit accountability into healthcare delivery, a system in which mistakes with tragic consequences are common.
Almost four years ago, several surgical and medication errors at accredited hospitals captured headlines. Those incidents sparked calls for more accountability and prompted the Joint Commission on Accreditation of Healthcare Organizations to consider its own accountability in helping reduce the risk of adverse outcomes.
We at the JCAHO knew we had to balance the public's expectations for patient safety with healthcare facilities' practical needs in dealing with "sentinel events"-incidents that could have caused or did cause death or serious injury to a patient.
One of our solutions was to encourage the use of root-cause analyses, whereby healthcare organizations that have experienced serious problems "dig down" into the underlying processes that might be changed.
The analyses reflect the fact that most sentinel events result from flawed processes, not incompetent individuals. Organizations that fire a person who made an error may find the same mistake repeated by other personnel. Instead, facilities need to evaluate the systemic processes involved in medication retrieval or surgical preparation, for example.
After two years of promoting root-cause analyses, we concluded that we still did not understand the epidemiology of healthcare errors.
Next we talked in-depth with healthcare professionals, business leaders and quality experts on the Joint Commission's board. We also hired a consultant to talk to key stakeholders-such as accredited organizations, regulatory bodies and consumers-about how to deal with sentinel events.
The JCAHO unveiled a new policy in 1997, encouraging accredited facilities to report sentinel events voluntarily. The policy thoroughly outlined what was reportable and what should be included in reports.
We believe that voluntary reporting improves patient safety most effectively. To encourage volunteerism, there is no penalty for reporting or failing to report a sentinel event.
The JCAHO uses the reports to look for trends. When we spot a pattern, we issue an alert including the number of events reported, the findings and the steps that facilities can take to reduce their risk of experiencing the problem. Alerts are sent to all accredited organizations.
Success story. Last year, for example, we sent an alert to nearly 18,000 healthcare facilities about 10 deaths involving the use of potassium chloride. Patients had inadvertently been given lethal doses of concentrated potassium chloride-a problem caused by confusion in the packaging and labeling of the drug.
The Joint Commission now advises healthcare organizations to limit concentrated doses of potassium chloride to their pharmacies unless they follow specific safeguards. We developed those guidelines from a review of root-cause analyses and discussions with experts outside the Joint Commission. A simple warning to remove a drug from floor stock or follow safeguards has saved lives.
Organizations that report sentinel events benefit by:
* Contributing what they've learned to the Joint Commission's database, which increases understanding of sentinel events and allows other organizations to avoid similar events.
* Consulting with Joint Commission staff while they're developing a root-cause analysis and action plan.
* Using their collaboration with the Joint Commission to reinforce their message to the public that they are doing everything possible to prevent sentinel events.
Accredited organizations have responded dramatically to the new policy. In the third quarter of 1998, nearly 90% of the sentinel events reviewed by the Joint Commission were self-reported, compared with a 9% rate during all of 1996.
In addition to self-reports from healthcare organizations, the Joint Commission still gets some reports from the media, HCFA, patients and their families, and site surveys.
The number of sentinel events averages between 10 and 20 per hospital per year, according to data from healthcare researcher Lucian Leape, M.D., and other experts. But the healthcare community still does not have a firm grasp on the frequency of sentinel events.
For example, our database shows that inpatient suicides are the most common type of sentinel event. Yet experts who study sentinel events believe fatal medication errors are most common. This discrepancy is likely caused by the fact that many medication errors go unreported.
Such disparities point to the need for greater awareness of sentinel events and for the Joint Commission's database. We must embrace the free exchange of sentinel event information while recognizing the legal liabilities.
Last year some accredited organizations said they were concerned that sending sentinel event information to the JCAHO might pose liability problems and be discoverable in lawsuits. As a result, we appointed a special task force, which recommended four additional options for organizations that want to protect their confidentiality. They can:
* Bring their documents to Joint Commission headquarters for review by staff, then take their documents with them when they leave.
* Request an on-site review of documents by a Joint Commission surveyor.
* Ask for an on-site visit by a JCAHO surveyor, who will conduct interviews and review documents to gather information about the root-cause analysis and resulting action plan. The surveyor would not review the organization's root-cause analysis.
* Request an on-site review of the organization's process for responding to a sentinel event and related policies and procedures.
We also developed two contractual arrangements facilities can use if they are concerned about the potential waiver of confidentiality protections in certain states.
The Joint Commission included confidentiality protections in the federal Patient Protection Act of 1998, which passed the House but not the Senate. This session of Congress presents a new opportunity for us. We also will work with state hospital associations that want to amend their peer review statutes.
The JCAHO is committed to ensuring confidentiality protections and the growth of voluntary sentinel event reporting.