Statement clarifies Joint Commission's sentinel event policy

A statement released in late January by several organizations clarifies the definition of severe maternal morbidity in The Joint Commission’s sentinel event policy. The joint statement was from the American College of Obstetricians and Gynecologists, the Association of Women’s Health, Obstetric and Neonatal Nurses, The Joint Commission, and the Society for Maternal-Fetal Medicine.

In January, The Joint Commission revised its definition of sentinel event to be a patient safety event that results in death, permanent harm, or severe temporary harm. Severe maternal morbidity is defined as a patient safety event that occurs intrapartum through the immediate postpartum period (24 hours) that requires the transfusion of four or more units of blood products (e.g., fresh frozen plasma, packed red blood cells, whole blood, platelets) and/or admission to the intensive care unit. The revision led to some confusion about the inclusion of severe maternal morbidities, since some cases may not meet criteria for a sentinel event. Thus, the definition will be revised to “four or more units of packed red blood cells” and will appear in the next accreditation manual updates.

Read the Joint Commission release here.