The Joint Commission has updated their sentinel event data, releasing data from the fourth quarter of 2017 and aggregating data from 2005-2017.
10 Most Reported Sentinel Events for Q4 2017
In 2017, 805 sentinel events were reported, with 87% of these events classified as self-reported. The following are the 10 most reported sentinel events from 2017, accounting for data from Q4:
- Unintended Retention of a Foreign Body
- Wrong-patient, wrong-site, wrong-procedure
- Delay in Treatment
- Other unanticipated event
- Criminal Event
- Medication Error
- Self-inflicted Injury
Aggregate Data: Top Outcomes from 2005-2017
The top five outcomes of the sentinel events from 2005-2017 are as follows:
- Patient death
- Unexpected additional care
- Permanent loss of function
- Severe temporary harm
- Psychological impact
According to TJC, this sentinel event-related data, reported to TJC by accredited organizations, “demonstrates the need of the Joint Commission and accredited health care organizations to continue to address these serious adverse events. This data also supports the importance of establishing National Patient Safety Goals and focusing our energies on addressing serious errors within health care organizations.”
Sentinel Event Settings
Sentinel event occurrence settings include multiple types of facilities, with the most common at Hospitals (67%), and psychiatric hospitals (9%).
What is a sentinel event?
The Joint Commission defines a sentinel event as:
“A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following:
- Permanent harm
- Severe temporary harm and intervention required to sustain life
TJC lists the frequency of sentinel events from 2005-2017, as well as the types of events that occurred in 2014-2017.
If a serious safety event has occurred in your organization, we can consult with your internal experts on the root cause analysis process to analyze near misses and sentinel events and prepare documentation for review by TJC. Learn about about our sentinel event and root cause analysis consultation services or contact our office at (513) 241.0142, via email at firstname.lastname@example.org, or via our contact page for a confidential discussion of your needs.
Additionally, we have conducted Patient Safety Assessments, in which we’ve helped other organizations take ownership of their patient safety strategies. if you have experienced a serious patient safety event and worry that your organization is vulnerable in other areas — or if you’ve had a near miss — we can help.