A process for analysis of sentinel events due to health care–associated infection

The Joint Commission on Healthcare Organizations (JCAHO) has received few reports of sentinel events involving health care–associated infection (HAI). The paucity of reporting may lead some to believe that deaths caused by HAI have been overestimated or that health care organizations do not recognize the events. Although the directive from the JCAHO seems clear, the process of identifying patients who died due to HAI versus those who died with an HAI is complex and requires a consistent evaluative methodology. This article proposes an algorithmic approach to identifying patients whose unanticipated death was related to an HAI, a data collection and report form, and a process for evaluating adherence to existing practices that are associated with best practices. The goals are to (1) stimulate dialogue among colleagues and improve the process so these events are reported to the JCAHO, (2) develop a process that blends with the existing root cause analysis matrix used in most health care organizations, and (3) develop interventions to prevent or correct practices that may contribute to sentinel events due to HAI.