Hospitals moan and groan about sentinel-event policy, but in the end they're learning to live with it.
The most recent statistics compiled by the Joint Commission on Accreditation of Healthcare Organizations show growing acceptance of its requirement that hospitals report any serious errors resulting in deaths or substantial injuries to patients.
Starting in the first quarter of 1998, the percentage of sentinel events that hospitals reported to the Joint Commission has mushroomed, although the total number of events-including those reported by hospitals, the media, patients and employees- has remained roughly constant (See chart, p. 36).
In a Feb. 3 report, the JCAHO said that in the most recent quarter, 30 of 38 known sentinel events, or 79%, were self-reported. That compares with 16 of 30, or 53%, in the first quarter of 1998, and two of 25, or 8%, in the first quarter of 1997.
JCAHO President Dennis O'Leary, M.D., said he wouldn't use the term "cooperation" to describe what's happening. " 'Comfort' is what I'd say. There is a steady flow of sentinel-event reporting, and it is holding up pretty well."
Experience is building hospitals' confidence, he said. "As organizations do this, learn from the root-cause analysis and make improvements based on that, and nothing bad happens, I think we'll see more and more reporting."
Hospitals conduct root-cause analyses by reviewing all procedures, systems and habits to find out where and how mistakes were made, and summarizing the results in reports.
The JCAHO's laboriously developed sentinel-event policy exploded in its face early last year when lawyers realized that sending the root-cause reports to the commission's headquarters in Oakbrook Terrace, Ill., could inadvertently void hospitals' protection from legal discovery. Peer-review documents normally are protected from legal discovery.
Lawyers for hospitals feared their facilities would be swamped with lawsuits filed by malpractice attorneys.
Hospitals in some states are more susceptible to this risk than others, depending on state laws and court precedents.
Hospitals also worried that the commission would not be able to refuse handing over potentially incriminating documents requested by court order.
To navigate around that problem, the Joint Commission devised four additional means for hospitals to complete root-cause analyses without exposing themselves to liability.
Each alternative lets the JCAHO get the gist of the report without keeping it on file at headquarters.
The commission's statistics show that very few hospitals are using these new alternatives; most are continuing to mail the completed reports. In the most recent quarter, only three hospitals chose the most restrictive form of sentinel-event reporting, and 28 root-cause analyses of 38 total events have been submitted to the JCAHO.
"I'm a little surprised about that," O'Leary said. "I know that some of those are coming from states that have no peer-review protections at all. They're doing it because they think it's the right thing to do, and they think we'll be able to protect them from any legal challenges, and we haven't had any yet."
One of those states is West Virginia, said Jim Kranz, vice president for professional activities at the West Virginia Hospital Association in Charleston.
"We have some precedents that make it very difficult for hospitals to send anything out of the building without significant risk," Kranz said. "If somebody comes on your campus to review the document, there's no problem. The second the hospital takes that document off campus, it becomes discoverable."
West Virginia hospitals must complete root-cause analyses regardless of whether they submit them to the Joint Commission, Kranz said. His association has conducted seminars on how to complete the reports.
"Whether they voluntarily turn those in or not is a hospital-specific decision," Kranz said. "We've not recommended one approach or the other."
The Joint Commission is using the database of 412 sentinel-event reviews to develop "alerts" based on lessons learned. In the past year it has published alerts on the prevention of potassium-chloride errors, wrong-site surgeries, inpatient suicides and deaths in restraints. These have been enthusiastically received, O'Leary said.
The number of sentinel events reported is probably just a small portion of the true volume of major errors, O'Leary said. Most experts believe that the failure to report sentinel events lies with employees, not leadership.
"I'll go out on a limb," O'Leary said. "The number being reported to us as a proportion of what organization chief executive officers know about is probably pretty good, but they probably know only a small portion of what's going on."
In January the Joint Commission required organizations to set up internal systems for reporting adverse events to hospital leaders.
"All of this is a commentary on the very difficult cultural issues," O'Leary said. "We live in a blame-and-punishment society. I don't care what kind of business you're in. The instinct is not to run and tell your boss about it."