UPDATE – Since I originally wrote this piece, the defendant in this case filed a motion for reconsideration and, in June, the Court granted that motion, ultimately reversing the previous decision regarding the sentinel event report. Continue to visit our blog for further updates on the developing law regarding the discoverability of JCHAO sentinel event reports, as well as other issues in Pennsylvania medical malpractice law.
In a case of first impression, the Lackawanna County Court of Common Pleas has ruled that a hospital’s Sentinel Event Report to the Joint Commission on Hospital Accreditation (JACHO) is not privileged and must be produced in litigation.
JACHO is a private, independent, non-profit organization that evaluates and accredits hospitals and healthcare organizations throughout the country. One of the things JACHO does is investigate and analyze “sentinel events.” Sentinel events are incidents involving patients, unrelated to the patient’s normal hospital course and treatment, which result in death or serious harm to the patient. Some of the more common “sentinel events” are surgical materials or devices retained or left behind inside patients, falls that occur at hospitals and hospital-acquired infections. When sentinel events occur, JACHO-accredited hospitals report them to JACHO by way of a Sentinel Event Report. JACHO analyzes the events and then works with the hospital to help them learn from the events and improve patient safety moving forward.
Often times, incidents that qualify as sentinel events result in lawsuits. The medical malpractice team at Stark & Stark has handled a number of cases involving serious injuries suffered by hospital patients that would qualify as sentinel events. Historically, hospitals and their attorneys have taken the position that JACHO Sentinel Event Reports are confidential and do not need to be turned over to the injured patient and his or her attorneys. Provisions of two statutes, the Peer Review Protection Act and the Medical Care Availability and Reduction of Error (MCARE) Act, permit hospitals to conduct candid internal reviews of adverse patient events without having to disclose the data from that process.
In Mallik v. Brink, Marion Community Hospital withheld a Sentinel Event Report concerning the incident that formed the basis for the lawsuit, arguing that it was protected from disclosure by the Peer Review Protection Act and MCARE. The Court disagreed and ruled that the Report is not protected and must be disclosed. The Court explained that a hospital’s voluntary reporting to a private organization does not constitute peer review, which involves an internal analysis by a peer review committee, and is not related to compliance with any portion of the MCARE Act.
This is an important ruling for injured patients. Often times these Sentinel Event Reports can provide relevant information about how and why an adverse incident occurred. This can be critical evidence in a lawsuit against the hospital.
If you or a loved one has suffered an adverse event while a patient at a hospital or other healthcare facility, such as a retained surgical object, a fall or an infection, it is recommended that you contact and experienced medical malpractice attorney immediately.