JCAHO Patient Safety Goal 7b: Nosocomial Infections as a Sentinel Event

ISSUE: The 2004 National Patient Safety Goal 7b as published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the organization “to manage as a sentinel event (SE) any unanticipated death or major permanent loss of function which results from a nosocomial infection.” PROJECT: We sought to develop a process to evaluate nosocomial infections as potential SEs given the severity of illness and underlying co-morbidities of patients hospitalized in the intensive care unit (ICU). The initial assessment of a potential nosocomial SE is made by the infection control practitioners (ICPs). This is followed by discussion of the specific issues related to the case with the medical director of the department, a board certified infectious disease physician. If the case meets the National Nosocomial Infection Surveillance criteria for defining the relationship of an infection to the patientʹs death, it is referred forward to the medical center medical director for evaluation as a nosocomial SE. RESULTS: The ICPs have learned to evaluate each death critically based on the natural course of illness or underlying conditions and the likelihood of survival of that hospitalization. This has resulted in a number of referrals of nosocomial infections for further review. LESSONS LEARNED: Evaluation of potential nosocomial SEs is extremely labor-intensive and should be evaluated using specific criteria before being referred forward as an SE. Sentinel events can result in positive outcomes such as improvements in communication, better educational tools, and improved patient outcomes.