• PR: – Clarifying Misconceptions About Sentinel Event Reporting  [Pearl: JCSC, Mdx, PI, LDR] Perspectives June 2013, Pg 9, Vol 33, #6

This article provides general encouragement for organizations to self-report sentinel events.  It raises several examples of misconceptions that may hinder such reporting unnecessarily.  One of these would relate to the statement ‘the patient came in very sick and just died’.  The point is made that any unexpected death is a reviewable event.  The challenge is to determine whether or not the death was a result of the natural course (i.e., expected) of the patient’s illness or not (i.e., unexpected).  If not, it is probably reviewable. Sometimes it is believed that if your state is one of the 25 that has its own mandatory requirement for reporting of sentinel events (e.g., GA, IL, IN, KS, NY, and SC), then self-reporting to TJC is unnecessary. The article seems to be encouraging self-reporting in this situation also.
Tip: Study note #4 on page 7 of the Sentinel Event Chapter regarding ‘natural course’. Then as permitted by LD.04.04.05, EP7, clarify in writing the definitions of ‘unexpected death’ and ‘natural course’ (before your next death occurs).