The JCRQSN program is a monthly series of video conference training sessions produced by 
Joint Commission Resources  (JCR) in partnership with The Wellness Network.  The Wellness Network is 
the distributor of the series and has no  influence on the content.  

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Sentinel Events Update: Improving Root Cause Analyses
and Actions to Prevent Harm

Premiere Date:
August 23, 2018

Program Description
The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events. Careful investigation and analysis of patient safety events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm. The Sentinel Event Policy explains how The Joint Commission partners with healthcare organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.

A sentinel event is a patient safety event that reaches a patient and results in any of the following:
  • Death. 
  • Permanent harm. 
  • Severe temporary harm and intervention required to sustain life. 

An event can also be considered a sentinel event even if the outcome was not death, permanent harm, or severe temporary harm.

Accredited organizations are expected to identify and respond appropriately to all sentinel events that occur in the organization or associated with services that the organization provides. Appropriate responses include conducting a timely, thorough, and credible root cause analysis, implementing improvements to reduce risk, and monitoring the effectiveness of those improvements.

Through in-depth expert discussion and examples, this program focuses on identification of and appropriate responses to sentinel events.

​After completing this module, the participant should be able to:
  • Describe the expectations of The Joint Commission’s Sentinel Event Policy.
  • Understand sources of physician disengagement in patient safety and root cause analysis and develop tactics to engage them.

Target Audience
This program is relevant to the entire organization and medical staff, organization leaders responsible for performance improvement (PI) initiatives, and staff involved in performance improvement activities.

Edward Pollak, M.D.
Medical Director and Patient Safety Officer
Division of Healthcare Improvement
The Joint Commission

This presenter does not have any financial arrangements or affiliations with corporate organizations that either provide educational grants to this program or may be referenced in this activity. This presenter has also attested that his discussion will not include any unapproved or off-label use of products.

Accreditation Information:
The Joint Commission is accredited by the Accreditation Council for Continuing Medical Education (ACCME-AMA PRA Category 1 ™), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

Note: No ACPE credit was provided for this program.  

The Joint Commission is provider approved by the California Board of Registered Nursing, provider number CEP 6381, for 1 contact hour.

The Joint Commission is authorized to award 1.0 contact hour of pre-approved ACHE Qualified Education credit for this program toward advancement or recertification in the American College of Healthcare Executives. Participants in this program wishing to have the continuing education hours applied toward ACHE Qualified Education credit should indicate their attendance when submitting application to the American College of Healthcare Executives for advancement or recertification.

This activity has been approved by the National Association for Healthcare Quality (NAHQ) for 1.0 Certified Professional Healthcare Quality (CPHQ) credit. 

The Joint Commission Enterprise has been accredited as an Authorized Provider by the International Association for Continuing Education and Training (IACET).

This education offering qualifies for 1.0 Certified Joint Commission Professional (CJCP) credit hours towards CJCP recertification. In order to obtain CJCP credit hours, an individual must first be certified before they start acquiring CJCP credit hours. CJCP credit hours will not be retroactive.

Full attendance at every session is a prerequisite for receiving full continuing education credits. If a participant needs to leave early, his or her continuing education credits will be reduced.

Successful completion of this CE activity includes the following:
  • View the presentation and read the accompanying Resource Guide.
  • Complete the online Evaluation Form and Post Test.
  • A CE certificate/statement of credit can be printed online following successful completion of the Post Test and the Evaluation Form