Not only has the Institute of Medicine (IOM) stressed patient safety but the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has always emphasized patient safety. JCAHO is a voluntary accrediting agency that assists to ensure safe medical standards of care that result in safe healthcare practices.
JCAHO has required, for many years, accredited member organizations to
perform a root cause analysis (RCA) for each sentinel event occurrence.
The healthcare organization may voluntarily inform
JCAHO of the sentinel event, or, if JCAHO learns of the sentinel event through
public media or when a survey is performed, JCAHO will mandate the completion of
a RCA if it has not already occurred. JCAHO at that point can seek additional
information on the specific sentinel event.[6]
For more detailed information on sentinel events
contact:
www.JCAHO.org. Concerns
are still being resolved on the prevention of discovery of sentinel events to
decrease litigation. If organizations voluntarily report sentinel events and
each sentinel event is then available publicly for litigation, organizations
will desire to keep sentinel events confidential from all sources. The need for
confidentiality is therefore important to encourage dissemination of lessons
learned.
JCAHO established in 1997 six National Patient Safety Goals that require
demonstrated compliance to maintain accreditation. The goals were selected by
JCAHO based on the following criteria:
A) had to have potential for
immediate improvement in patient safety
B) based on evidence or expert
consensus
C) had to be practical,
cost-effective, and well-defined