The Joint Commission created the first Sentinel Event policy in 1996. Since that time, the organization has collected and maintained information on sentinel events. The latest Sentinel Event Annual Review was recently released by the Joint Commission, offering the 2022 update.
The Joint Commission is a non-profit organization based in the US that provides accreditation to US health programs, institutions, and care organizations.
Overall, the report contains information on causes and outcomes of sentinel events. A sentinel event is one that leaves a patient with serious harm, permanent injury, or death. The harm that constitutes a sentinel event usually begins with a “Never Event,” a preventable medical error that should never happen.
For the 2022 report, data was reported to the Sentinel Event database between January 1, 2022 to December 31, 2022. Approximately 1,441 sentinel events were reported, which constitutes a 19 percent increase in the number of sentinel events reported in 2021. It is important to remember reporting to Sentinel Event database is voluntary—which means the total number of serious harm events is far greater than the number reported to The Joint Commission.
Points of the report include:
- Approximately 13 percent of the reports involved errors that led to a longer hospital stay or additional treatment. About 44 percent resulted in severe temporary harm, while 20 percent involved a patient death.
- The Joint Commission also has a lengthy list of events that are automatically considered a sentinel event, only a few of which include patient suicide, maternal morbidity leading to severe or permanent harm, physical assault, wrong site surgery, or accidental retention of a foreign object following surgery.
The top 10 types of sentinel events for 2022 include:
- Patient falls
- Delay in treatment
- Retention of a foreign object
- Wrong surgery
- Perinatal event
- Medication management
Patient falls are a perennial root cause of patient harm. There was a 27 percent increase in the number of patient falls in 2022, over 2021. At number two, delay in treatment can be deadly, with the most frequent outcome being death. There were fewer reports involving unintended retention of a foreign body after surgery in 2022 and there were 85 sentinel events involving wrong site surgery.
Sentinel events that result in serious harm or death remain too common. If you, or your family, are seriously injured through a medical mistake—speak with our legal team about your options.
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Schochor, Staton, Goldberg, and Cardea, P.A. is a trusted law firm representing patients injured through medical error. If you are injured by medical error, we can help. Contact us or call 410-234-1000 to schedule a free consultation. We have offices in Washington, DC and Baltimore, Maryland.