joint commission sentinel event policy 2021

“RSIs are understandably deemed surgical never events, so continued research into their root causes and interventions focused on their prevention and mitigation remain critical,” the coauthors wrote, adding that many aspects of the study deserve praise.Īccording to Drs. Kaafarani, MD, MPH, FACS, wrote “… a review of sentinel events for RSIs submitted to The Joint Commission between 20, the majority of reported RSIs were due to absence of or failure to comply with preventive policies and procedures.” †

DeWane, MD, and Joint Commission chief patient safety officer and medical director Haytham M.

RSI bundle compliance rate of 70.5%, with 63.2% of the facilities actively performing Plan-Do-Check-Act (PDCA) cycles to improve bundle compliance continually.

59.1% increase in RSI near-miss reporting.

14.3% reduction in the rate of harm caused by RSIs.

The results of implementing the RSI bundle were: From there, a workgroup determined an “evidence-based best practice bundle” that incorporated five elements:

The study-A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items, * by April Carmack, MSN, RN, SSBBP, and coauthors-included a total of 114 healthcare facilities. URFOs are the fourth most frequent sentinel event reported to The Joint Commission, with 94 instances occurring in 2021 and 30 events in the second quarter of 2022.Ī new study published in The Joint Commission Journal on Quality and Patient Safety found that implementation of a retained surgical items (RSI) bundle can improve reliability and near-miss reporting while also reducing harm to patients. Unintended retention of foreign objects (URFOs) remains a critical patient safety issue in surgery.

Joint commission sentinel event policy 2021