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Alternatives for Reporting Sentinel Events to JCAHO

. . . if the organization has concerns about increased risk of legal exposure as a result of sending the root cause analysis documents to the Joint Commission, the following alternative approaches to review of the organization's response to the sentinel event are acceptable.

(1) Review of root cause analysis documents brought to Joint Commission headquarters by organization staff, then taken back to the organization on the same day.

(2) An on-site visit by a specially trained surveyor to review the root cause analysis and action plan. The organization will be assessed a charge sufficient to cover the average direct costs of the visit.

(3) An on-site visit by a specially trained surveyor to review the root cause analysis and findings, without directly viewing the root cause analysis documents, through a series of interviews and review of relevant documentation. For purposes of this review activity, "relevant documentation" includes, at a minimum, any documentation relevant to the organization's process for responding to sentinel events, and the action plan resulting from the analysis of the subject sentinel event. The latter serves as the basis for appropriate follow-up activity. The organization will be assessed a charge sufficient to cover the average direct costs of the visit.

(4) Where the organization affirms that it meets specified criteria respecting the risk of waiving legal protection for root cause analysis information shared with the Joint Commission, an on-site visit by a specially trained surveyor to conduct interviews and review relevant documentation to obtain information about

  1. the process the organization uses in responding to sentinel events, and,

  2. the relevant policies and procedures preceding and following the organization's review of the specific event, and the implementation thereof, sufficient to permit inferences about the adequacy of the organization's response to the sentinel event.

The organization will be assessed a charge sufficient to cover the average direct costs of the visit.

  Click here to link to the entire text at the Joint Commission's website.


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About MRMA.  Automate Root Cause Analysis.  Root Cause Analysis Training Comments.  Copyright.  Costeffective Root Cause Analysis.  Credible Root Cause Analysis.  Protection from Discoverability.  Reporting of Sentinel Events to JCAHO.  Root Cause Analysis Cost.  JCAHO Requirement for Root Cause Analysis  JCAHO Sentinel Event Reporting Options.  Proximate cause, root cause versus contributory factor.  Root Cause Analysis on Non-Sentinel Events.  RCA on Sentinel versus Adverse Event.  Reaction to JCAHO Sentinel Event Policy.  Suicide RCA Data.  Root Cause Analysis Policy Implementation.  Root Cause Analysis Standards.  Software facilitation of root cause analysis.  Thorough & Credible Root Cause Analysis.  DoD Sentinel Event Reporting.  Literature Review in Root Cause Analysis.  Root Cause Analysis Training.  FAQ's on Root Cause Analysis.  FOCUS-PDCA.  Guestbook.  Implementing Root Cause Analysis Policy.  MRMA Home.  Inforequest.  Links.  Patient-Doctor Dialog.  Freedom from Restraint.  JCAHO Reporting Options.  Root Cause Analyst.  Thankyou.  Root Cause Analysis Theory.  Root Cause Analysis Training.  Root Cause Analysis Training.  Sample Root Cause Analysis Report.  Sample RCA Contributory Factor Tree Diagram.  Root Cause Analysis Reporting Form. 
About MRMA.  Automate Root Cause Analysis.  Root Cause Analysis Training Comments.  Copyright.  Costeffective Root Cause Analysis.  Credible Root Cause Analysis.  Protection from Discoverability.  Reporting of Sentinel Events to JCAHO.  Root Cause Analysis Cost.  JCAHO Requirement for Root Cause Analysis.  JCAHO Sentinel Event Reporting Options.  Proximate cause, root cause versus contributory factor.  Root Cause Analysis on Non-Sentinel Events.  RCA on Sentinel versus Adverse Event.  Reaction to JCAHO Sentinel Event Policy.  Suicide RCA Data.  Root Cause Analysis Policy Implementation.  Root Cause Analysis Standards.  Software facilitation of root cause analysis.  Thorough & Credible Root Cause Analysis.  DoD Sentinel Event Reporting.  Literature Review in Root Cause Analysis.  Root Cause Analysis Training.  FAQ's on Root Cause Analysis.  FOCUS-PDCA.  Guestbook.  Implementing Root Cause Analysis Policy.  MRMA Home.  Inforequest.  Links.  Patient-Doctor Dialog.  Freedom from Restraint.  JCAHO Reporting Options.  Root Cause Analyst.  Thankyou.  Root Cause Analysis Theory.  Root Cause Analysis Training.  Medical Risk Management Associates.  Sample Root Cause Analysis Report.  Sample RCA Contributory Factor Tree Diagram.  Root Cause Analysis Reporting Form.