![]() ![]() In Touch Isfor The Joint Commission Nursing Care Center Program.Joint Commission Publishes Most Challenging Primary Care Medical Home Requirements.June 8: The Joint Commission, AORN Recognize ‘National Time Out Day’.Therefore, the data is epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. The Joint Commission cautions that the reporting of most Sentinel Events is voluntary and represents only a small proportion of actual events. By identifying causes, trends, settings and outcomes of Sentinel Events, The Joint Commission can provide critical information in the prevention of Sentinel Events to accredited health care organizations and to the public. The data also supports the importance of establishing National Patient Safety Goals (NPSGs) and focusing energies on addressing serious errors within health care organizations. ![]() Sentinel Event-related data demonstrates the need of the Joint Commission and accredited health care organizations to continue to address serious adverse events. Sentinel Event Data Summary (2004 – 2015).Sentinel Event Statistics Data – General Information (1995 – 2015).Sentinel Event Statistics Data – Event Type by Year (1995 – 2015).Sentinel Event Statistics Data – Root Causes by Event Type (2004 – 2015).Links to the individual Sentinel Event presentations are included below. Since 2004, the majority of reviewed Sentinel Events (6,416, 67%) occurred in an acute hospital setting. Data for these analytics from 1995 to 2003 is not provided.Īccording to the latest statistics, since 2004 The Joint Commission has reviewed 9,581 Sentinel Events, determined 9,884 patients were impacted by these events, and identified 5,540 (56.1%) of the events resulted in patient death and 929 (9.4%) resulted in permanent harm or permanent loss of function. In 2011, The Joint Commission began presenting data for specific analytics dating back to 2004 only, including reporting source, Sentinel Event setting, and Sentinel Event outcome. Since The Joint Commission implemented the Sentinel Event database in January 1995 the organization has reviewed a total of 12,122 Sentinel Events and issued 55 Sentinel Event Alerts, the most recent being Sentinel Event Alert #55: Preventing Falls and Fall-Related Injuries in Health Care Facilities on September 28, 2015. In all, The Joint Commission reviewed 936 sentinel events in 2015 compared to 764 in 2014. In 2014, delay in treatment events ranked no.4, with 73 reviews, and operative/post-operative complications ranked no.7 with 52 events. ![]() Both sentinel events were reviewed 76 times in 2015. Finally, rounding out the top six, at no.5 and no.6, were delay in treatment events and operative/post-operative complications. ![]() Comparatively, falls were no.2 (91) and suicide was no.3 (82) in 2014. Fall-related events and suicide were no.3 and no.4, as both reviewed 95 times in 2015. The no.2 most reviewed sentinel event was wrong-patient, wrong‐site, wrong‐procedure surgery (111), an increase from 67 in 2014 were it was the no.6 most reviewed sentinel event. Unintended Retention of a Foreign Body remained the no.1 most reviewed sentinel event in 2015 (116, compared to 112 in 2014). The Joint Commission has updated its Sentinel Event statistics through 2015, and published four related presentations. ![]()
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