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
© Copyright, The Joint Commission
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
© Copyright, The Joint Commission
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
© Copyright, The Joint Commission
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
© Copyright, The Joint Commission
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
© Copyright, The Joint Commission
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)