Sentinel Event Data - Joint Commission

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The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural ... 2012. 2013. Num ber of Ev ents Rev iew ed by. TJC. Sentinel Event Alert. #9: "Infant Abductions" .... Kernicterus". August 2004 ...
Sentinel Event Data 1995 – 2013

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Event Type by Year

Sentinel Event http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/

 A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

 The term “sentinel event” and “medical error” are not synonymous; not all sentinel events occur because of an error, and not all error result in sentinel events. 2

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 Such events are called “sentinel” because they signal the need for immediate investigation and response.

.

Reviewable Sentinel Events  The event has resulted in an unanticipated death or major permanent loss of function, not related to the natural course of the patient’s illness or underlying condition. OR  The event is one of the following and does not require an outcome of death or major permanent loss of function:  Suicide of any patient receiving care, treatment and services in a staffed around-theclock care setting or within 72 hours of discharge.  Unanticipated death of a full-term infant  Abduction of any patient receiving care, treatment, and services  Discharge of an infant to the wrong family  Rape  Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities  Surgical and nonsurgical invasive procedures on the wrong patient, wrong site, or wrong procedure  Unintended retention of a foreign object in a patient after surgery or other procedure  Severe neonatal Hyperbilirubinemia (bilirubin >30 miligrams/deciliter)  Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose 3

© Copyright, The Joint Commission

http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

4

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Data Limitations

Abduction Events Reviewed by The Joint Commission (Of any individual receiving care, treatment or services)

25 20

Sentinel Event Alert #9: "Infant Abductions" April 1999

15

9 4

4

4

4

2 2013

1

3

2012

1

2011

2008

2007

2006

2005

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

1

2010

3

2009

1

2 2004

2

2003

2

2002

2000

1999

1998

0 1997

0

1996

0

3

2001

5

7

5

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10

1995

Number of Events Reviewed by TJC

30

Anesthesia-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

Sentinel Event Alert #32: "Anesthesia Awareness" October 2004

25 20

14

15

16

15

12 10

10 4

5 0

1

6 3

4

6

6

7

6

8

0 2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

0

8

8

6

© Copyright, The Joint Commission

Number of Events Reviewed by TJC

30

Criminal Events -- Assault/Rape/Homicide Reviewed by The Joint Commission (Rape defined as un-consented sexual contact. One or more of the following must be present to determine reviewability: Any staff witnessed sexual contact; or sufficient clinical evidence or admission by the perpetrator)

80

Sentinel Event Alert #45: "Preventing Violence in Healthcare Settings" June 2010

60 49

50

42

40

35

34

30 20

7

11

16

16 9

13

43

28

20

3 2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1 1997

0

0

1996

10

12

15

52

7

© Copyright, The Joint Commission

70

1995

Number of Events Reviewed by TJC

90

Delay in Treatment Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 138

140

123 Sentinel Event Alert #26: "Delay in Treatment" June 2002

120 100

103

95

113

50

18

20

42

26

18

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2001

2000

1999

1996

1998

3

1997

1

7

37

2003

40

36

2002

35

54

8

© Copyright, The Joint Commission

60

0

107

78

80

1995

Number of Events Reviewed by TJC

160

Elopement-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

25 20 14 12

11

10 7

7

7

2013

2012

2011

2010

2007

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

9

4

2009

5

2008

5

2006

2005

2004

2003

2002

2001

2000

1999

1 1998

1995

1

1997

0

10 8

4

5 0

7

8

11

9

© Copyright, The Joint Commission

15

1996

Number of Events Reviewed by TJC

30

Fall-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

96

100 81

Sentinel Event Alert #14: "Fatal Falls-Lessons for the Future" July 2000

76 63

60

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

1997

2007

1996

2006

2

18

2005

2001

2

1998

0

17

2004

2000

13

2003

21

2002

25

1999

20 0

35

31 23

56

53

47 40

82

10

© Copyright, The Joint Commission

80

1995

Number of Events Reviewed by TJC

120

Fire-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

Sentinel Event Alert # 29: "Preventing Surgical Fires" June 2003

Sentinel Event Alert #17: "Fires in the Home Care Setting" March 2001

25 20

16

15

15

7 5

8

7

9

8

4 2 2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1996

1998

0 1997

0

1995

0

3

9 7

4

15

12

11

10

15

11

© Copyright, The Joint Commission

Number of Events Reviewed by TJC

30

Hyperbilirubinemia Events Reviewed by The Joint Commission (Bilirubin > 30 milligrams/deciliter)

20 15

Sentinel Event Alert #31: "Revised Guidelines to Help Prevent Kernicterus" August 2004 Added to Sentinel Event Policy in 2005

10

5 2 2009

0 2013

2008

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

0 2012

0

1 2011

0

2010

0 2007

0

2006

0

2005

0

1

12

© Copyright, The Joint Commission

25

Sentinel Event Alert #18: "Kernicterus Threatens Health of Infants" April 2001

2004

Number of Events Reviewed by TJC

30

Infection-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 28 Sentinel Event Alert #28: "Infection Control Related Sentinel Events" January 2003

25 20

Sentinel Event Alert #22: "Preventing Needle Stick & Sharp Injuries" August 2001

22

21

20

14 11

2002

2003

12

12

2008

11

12

2007

15

12

13

4

5

2

1

1

2013

2012

2011

2010

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2009

2006

2005

2004

2001

2000

1999

1998

0 1997

0

1996

0

2

13

© Copyright, The Joint Commission

10

1995

Number of Events Reviewed by TJC

30

Inpatient Drug Overdose Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

25

22 19

20 15

7

7

7

7

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2004

3

2006

4

2005

3

2003

2002

1997

4

2001

0

4

2000

0

3

1999

0

1996

0

4

1998

5

6

8

8

14

© Copyright, The Joint Commission

10

1995

Number of Events Reviewed by TJC

30

Maternal Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) Sentinel Event Alert # 44: "Preventing Maternal Death" January 2010

20 15

15 9

5

3

10 8

7

5

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2000

1999

1996

4

3

1998

0 1997

0

5

2002

5

2001

6

10

18

13

12

10

0

16

15

© Copyright, The Joint Commission

25

1995

Number of Events Reviewed by TJC

30

Medical Equipment-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

35 30

39

26

25

24

23

20

19

20 15

17

13

5

7

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2001

2000

2005

9

2004

8

5

1999

1996

1998

0 1997

0

10

2003

6

7

9

2002

10

0

25

16

© Copyright, The Joint Commission

40

Sentinel Event Alerts # 15: "Infusion Pumps" November 2000 #21: "Medical Gas Mix-ups" July 2001 #36: "Tubing Misconnections" April 2006 #38: "MRI" February 2008

1995

Number of Events Reviewed by TJC

45

Medication Error Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

70 60

53

50

40 26

27

30

2006

21

20

44

45

38

30

30

43

2010

39

40

2009

47

50

42

38

7

10 0

2013

2012

2011

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

0

59

17

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80

Sentinel Event Alerts #11: "High -alert meds" November1999 #16: "Mix -up leads to a Med Error" February 2001 #19: " Look-alike/sound-alike" May 2001 #23: "Abbreviations" September 2001 #35: "Medication reconciliation" January 2006 #39: "Pediatric med Errors" April 2008 #41: "Anticoagulants" September 2008

2005

Number of Events Reviewed by TJC

90

Op/Post-op Complication Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

133

Sentinel Event Alert #12: "Operative and PostOperative Complications" February 2000

120 100

94

80 58

60 40

70

62 51

48

53

75

83

71

77

49

28

20

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1996

1998

1

9 1997

0 1995

0

75

86

18

© Copyright, The Joint Commission

Number of Events Reviewed by TJC

140

Other Unanticipated Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function--such as: asphyxiation, choking, drowning, found unresponsive) 81

80

71

70

65 51

47

50

40

40

33

38

11

10

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

1997

2000

1 1999

1

1998

0

1996

0

41

34

31

30 20

48

40

56

52

19

© Copyright, The Joint Commission

60

1995

Number of Events Reviewed by TJC

90

Perinatal Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function--full-term infant 2500g or > and absence of obvious congenital abnormality)

80

Sentinel Event Alert #30: "Preventing Infant Death & Injury in Delivery" July 2004

70 60 50

36

36

35

2011

2012

2013

19

2007

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

20

© Copyright, The Joint Commission

14

2006

11

16

2005

10

2004

13

2003

1999

1 1998

2

1997

0

0

1996

10

12

2002

10

2001

17

2000

20

31

2010

24

31

2009

30

32

2008

40

1995

Number of Events Reviewed by TJC

90

Radiation Overdose Events Reviewed by The Joint Commission (Cumulative dose > 1500 rads to a single field, or any delivery of radiotherapy to the wrong body region or > 25% above the planned radiotherapy dose)

25 20 15

Added to Sentinel Event Policy in 2005

10

8 5

5 0

8

0 2005

1 2006

2

3

2007

2008

3

2009

2010

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2011

2012

4

2013 21

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Number of Events Reviewed by TJC

30

Restraint-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

25

Sentinel Event Alert #8: "Preventing Restraint Deaths" November 1998

26

25 23

20

18

17

16 14

15

12

15

14

12

13

11

10 6

5

5

4

2 0

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

0

7

22

© Copyright, The Joint Commission

Number of Events Reviewed by TJC

30

Self-inflicted Injury Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function--not related to suicide)

25 20 14

15

9 7

6

1 2013

2012

2011

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2010

2005

2004

2003

2002

2001

2009

2000

2

6

4

2007

2

4

2006

2

3

4

0 1998

0

1997

0

1996

0

3

1999

5

6

2008

7

23

© Copyright, The Joint Commission

10

1995

Number of Events Reviewed by TJC

30

Suicide Events Reviewed by The Joint Commission (Of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 72 hours of discharge)

100

Sentinel Event Alert #7: "Inpatient Suicides: Recommendations for Prevention" November 1998

80

Definition revised to include suicide within 72 hours of discharge: March 2005

69

87 71

63 49

40

103

53

55

2006

58

60

66

48

30

131

85

90

67

33

20 4 2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

0

0

24

© Copyright, The Joint Commission

120

Sentinel Event Alert #46: "A Follow-Up Report on Preventing Suicide" November 2010

2005

Number of Events Reviewed by TJC

140

Transfer-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

25

20 15 10 5

3

3

2

2013

2012

2011

2010

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2 2009

2

3 2008

2005

1

2007

2

2006

0

1 2004

1

2003

2000

1999

1

2002

2

2001

3 1998

0 1997

0

1996

0

3

3

25

© Copyright, The Joint Commission

7

1995

Number of Events Reviewed by TJC

30

Transfusion-related Events Reviewed by The Joint Commission (Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities)

25 Sentinel Event Alert # 10: " Preventing Future Occurrences" August 1999

20

18

11 6 5

13

13

10

10

12

10

6

7

6

5

3 0

1 2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

0

16

14

15

20

19

26

© Copyright, The Joint Commission

Number of Events Reviewed by TJC

30

Unintended Retention of Foreign Object Events Reviewed by The Joint Commission

180

160

188

Added to SE Policy June 2005

140 119

120

133

115

100

102

78

80

70

53

60 40 20

2013

2012

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2011

2010

2009

2008

2007

2006

2005

0

17

27

© Copyright, The Joint Commission

Number of Events Reviewed by TJC

200

Ventilator-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function)

25 20 Sentinel Event Alert #25: "Preventing Ventilator Deaths & Injuries" February 2002

10

7

5

4

5

4

1

1

4

6

6

5 3

2 0

2013

2012

2011

2010

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1998

0 1997

0

1996

0

2

5

8

7

28

© Copyright, The Joint Commission

15

1995

Number of Events Reviewed by TJC

30

Wrong-patient, Wrong-site, Wrong-procedure Events Reviewed by The Joint Commission 160 140

100 80

93

75

67 53

50

2004

40

40

26

2013

2012

2011

2010

2009

The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

2008

2007

2006

2005

2002

2001

1997

2000

3 1999

2

1998

0

1996

20 0

56

60

109 109

94

90

2003

60

116

Sentinel Event Alert "Follow-up Review of Wrong Site Surgery" December 2001 Sentinel Event Alert #6: "Wrong-Site Surgery" August 1998

152

149

29

© Copyright, The Joint Commission

120

Wrong Site Surgery Summit II February 2007

NPSGs: January 2003 Wrong Site Surgery Summit I May 2003

1995

Number of Events Reviewed by TJC

(Regardless of the magnitude of the procedure)