Updated statistics from the Joint Commission show 887 sentinel events were reported in 2013. The most frequently reported sentinel event in 2013 was delay in treatment, followed by wrong patient, wrong site or wrong procedure.
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, including any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The Joint Commission data shows that a total of 7,881 patients have been effected by sentinel events from 2004-2013, with 59.1 percent resulting in the patient’s death, 31.4 percent resulting in unexpected additional care and/or psychological impact, and 9.5 percent resulting in loss of function.
The Joint Commission learns about sentinel events either voluntarily from accredited organizations or through other mechanisms, such as complaint processes or media coverage. It is estimated that less than 2 percent of all sentinel events are reported to the Joint Commission, and that only about two-thirds of these are voluntarily reported by the organization. The data is not an epidemiologic data set, and no conclusions should be drawn from the actual relative frequency of events or trends in events over time.
The Joint Commission Sentinel Event database is designed to increase the general knowledge about sentinel events, their contributing factors and strategies for prevention. For more information, visit the Joint Commission sentinel event Web page.
