New Sentinel Event categories focus on Post-Discharge Suicides

By A.J. Plunkett

Expect even more focus on how hospitals help patients at risk of suicide soon after discharge following data showing that two suicide-related categories make up the top five sentinel events (SE) for the first half of 2019 according to data from The Joint Commission (TJC).

While suicide overall often has been in the top sentinel events, this breakdown includes two categories that split suicide events into those involving an inpatient and events involving a patient within 72 hours of discharge.

While both categories were tied at 21 investigated events in the first half of 2019, TJC also notes that historically only 2% of all sentinel events are reported to the accrediting organization.

The categories are among an expanded breakdown implemented by TJC in August 2018 that also includes suicide events in emergency departments.

The more precise categorizations of when and where patient suicides occur is among escalating efforts by TJCand CMS to have hospitals step up its work to address and reduce suicide risk.

That includes TJC overhauling National Patient Safety Goal (NPSG) 15 as of July 1 to not just identify patients at-risk for suicide but to specifically “reduce the risk for suicide.”

The revisions expanded the three previous elements of performance into seven that outline requirements for environmental risk assessments, evidence-based suicidal ideation screening, training of hospital personnel to care for suicidal patients, and efforts to counsel and provide to follow-up care at discharge.

The new NSPG challenges hospitals “to properly screen and assess patients and take appropriate action on the results of those screenings and assessments,” says Jennifer Cowel, RN, MHSA, president of Patton Healthcare Consulting in Naperville, Illinois, and a former TJC executive.

“I think that the recent release of sentinel event statistics will dovetail into the new NPSG on suicide.  Almost all hospital have heard the message about suicide and have made strides to at least make their behavioral health spaces ligature resistant. The NPSG certainly moves the field way beyond just having a safe space,” says Cowel.

“With suicide rates in the country rising and the SE statistics just the tip of the iceberg on what is happening in hospitals, the newly released data will put urgency behind implementing the full set of NPSG changes.”

Of particular interest is the “split between in-house suicide versus the community suicide after discharge,” says Cowel, with a recommendation for hospitals to use that as a takeaway to “focus on an appropriate discharge plan and referrals.”

Unintended retention still tops

Leading all categories in the first half of 2019 was the sentinel event that has long topped the list: the unintended retention of a foreign body during invasive procedures, including surgery. TJC said there were 60 such events in the first half of this year.

That was more than twice as many events that fell into the second highest category, that of wrong site, wrong patient or wrong procedure errors during invasive procedures.

Third was falls-related events at 25, followed by the two suicide categories tied for fourth and fifth in the top five.

While TJC expects hospitals to track, investigate and learn from adverse events as outlined under Leadership standard LD.03.09.01, it notes that self-reporting of events to TJC as outlined in the Sentinel Event chapter of the hospital manual on accreditation is voluntary.

Of the 436 sentinel events reviewed by TJC in the first half of 2019, the majority — or 361 events (83%) — were voluntarily self-reported. Of the 75 non-self-reported events, 72 (or were reported by patients or their families, employees “current or former,” or through TJC’s online patient safety reporting process, said TJC officials in the October issue of its Perspectives online magazine.

Noting similar statistics on reporting for all of 2018, Patton Healthcare Consulting told clients in its own newsletter earlier this year that “it would appear that some patients and staff must be reading your websites, patient rights posters, or APR policies.”

Editor’s note: A.J. Plunkett is editor of the Simplify Compliance newsletter Inside Accreditation & Quality.