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The Joint Commission

The Joint Commission (formerly referred to as JCAHO or "Jayco") is well known to most of us. Its mission is to "continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations."

Cases considered reviewable under the Joint Commission's Sentinel Event Policy are "any perinatal death or major permanent loss of function unrelated to a congenital condition in an infant having a birth weight greater than 2500 grams." The Joint Commission has compiled a list of recommendations related to organizational culture and communication as well as risk reduction strategies identified by hospitals during their root cause analysis of sentinel events.

Communication is cited as a root cause of perinatal death and injury in over 80 percent of cases, leading all other causes. - JCAHO Root Causes of Perinatal Deaths and Injuries, 1995-2004

Despite the health care system's dependence on team coordination and communication to achieve optimal outcomes, disciplines rarely engage in joint training. - Louis P. Halamek MD, Stanford School of Medicine, 2003

Sentinel Event Alert Issue #30: Preventing Infant Death and Injury During Delivery identifies root causes and risk reduction strategies, makes recommendations, and cites references. This document is frequently cited, and all obstetrical physicians, nurses, and midwives should be familiar with it. This sentinel event-related data demonstrates the need to continue to address these serious perinatal adverse events. This data also supports the importance of establishing national patient safety goals. By identifying causes, trends, settings and outcomes of sentinel events, the Joint Commission can provide critical information in the prevention of sentinel events.

For more information on the Obstetric Safety Initiative, or to offer suggestions for this site, contact us.

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