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Joint Commission now reviewing baby switch at Heartland Regional

BY JOHN HOMAN, The Southern

Tuesday, April 15, 2008 6:18 PM CDT

MARION — A spokeswoman with The Joint Commission, the nation’s predominant accrediting body in health care based in Oakbrook Terrace, confirmed Tuesday that the agency was now aware of a baby-switching incident at Heartland Regional Medical Center in Marion.

Elizabeth Zhani, media relations specialist for The Joint Commission, said the policy of the commission prevented her from revealing the source for the information. She said the agency is working with the hospital in accordance with the Sentinel Event Policy, which is designed to prevent such an occurrence from happening again, enhancing patient safety.

When a sentinel event occurs, she said, the accredited organization — Heartland Regional Medical Center in this case — is required to complete a thorough and credible root cause analysis, implement improvements to reduce risk and monitor the effectiveness of those improvements.

Some reviewable sentinel events include: suicide of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge; unanticipated death of a full-term infant; abduction of any individual receiving care, treatment or services; discharge of an infant to the wrong family; rape; hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibles.

Zhani said there is no reason to think that the hospital won’t follow policy. But for those organizations that don’t, they run the risk of losing their accreditation.

Zhani added that staff members were not on site conducting a survey at Marion Tuesday.

“All of our surveys are unannounced,” she said.

During an on-site survey, the surveyor will assess the organization’s compliance with sentinel event-related standards by reviewing the organization’s process for responding to a sentinel event, interview the organization’s leaders and staff about response to sentinel events and ask for an example of a root cause analysis that has been conducted in the last year.

After the Joint Commission has determined that an organization has conducted an acceptable root cause analysis and developed an acceptable action plan, the agency will notify the organization that its root cause analysis and action plan are acceptable and will assign an appropriate follow-up activity, typically one or more sentinel event measures of success due in four months.

Hospital spokeswoman Staci Bynum reiterated Tuesday that she could not answer any questions or make any comments at this time.