Dear Colleague:

I am writing to draw your attention to several types of reportable sentinel events for which there appear to be disproportionately low frequencies in the Joint Commission's Sentinel Event Database. I make specific reference to unanticipated deaths or permanent loss of function in patients which:

Appear to be related to nosocomial infections.
For long term care services, are reportable to federal and state agencies as part of the Minimum Data Set (MDS).
For home care services, are reportable to federal and state agencies as part of the OASIS requirements.
While I understand that such occurrences are often already being reported to various government agencies, I want to remind you that the Joint Commission's Sentinel Event Database is the only national database that regularly takes in and categorizes information on all types of sentinel events and their underlying causes. As such, it is a unique resource both for your accredited organizations and for patient safety experts.

Reporting to the Sentinel Event Database continues to be voluntary. While the Joint Commission has thus far been able to maintain the confidentiality of all sentinel event information reported to it to date, we do understand that confidentiality concerns limit the number of cases actually brought to our attention. Nevertheless, we have until recently believed that the Database is representative of the broad universe of sentinel events.

Now, in retrospect, it appears that we are receiving a disproportionately low volume of reports on the three categories of sentinel events listed above. In view of the importance and high visibility of such occurrences, we urge you to share this information with the Joint Commission, just as you might share information about other types of sentinel events with us. Given the nature of these events, we believe it likely that you will have already conducted the related in-depth analyses anticipated by Joint Commission standards.

In sum, the Joint Commission is especially interested in receiving reports of nosocomial infections that lead to death or permanent injury in a single patient, or where relevant, groups of patients; and reports on unanticipated deaths or permanent patient injuries from any cause in long term care and home care settings. All of the sentinel event information received by the Joint Commission serves as the principal data source for the Sentinel Event Alerts that are issued approximately six times per year and for the formulation of the Joint Commission's Annual Patient Safety Goals.

Thank you for your interest and your assistance. Please let me know if you have any questions or concerns.

Sincerely,

Dennis S. O'Leary, M.D.
President