Revised Sentinel Event Policy Emphasizes Postevent Focus on Systems Vulnerabilities

January 22, 2016 | Strategic Insights for Ambulatory Care


​Revisions to the Joint Commission's sentinel event policy and procedures emphasize that accredited organizations should focus their postevent analysis on "system vulnerabilities" rather than on individual healthcare worker actions. The revisions, announced January 6, 2016, require a "comprehensive systematic analysis" that will "seek out underlying systems-level causations that were manifest in personnel-related performance issues."

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