New sentinel event data has been released by The Joint Commission to help accredited organizations mitigate and prevent future harm to care recipients. The Joint Commission has reviewed 569 sentinel events from Jan. 1 through June 30, 2021 with the majority of these — 91% (516) — being voluntarily self-reported by an accredited or certified entity.
The remaining 53 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. Despite the continued challenges presented by COVID-19, the number of sentinel events remained comparable to previous years.
“COVID continues to impact patient care and healthcare operations in myriad ways,” stated Raji Thomas, DNP, MBA, CPHQ, CPPS, Director of the Office of Quality and Patient Safety (OQPS), The Joint Commission. “However, we have seen the unrelenting resilience of healthcare organizations and their commitment to patient safety and quality of care. The emergence of newer variants of COVID pose additional challenges to organizations, including difficulty ensuring safe staffing and clinician well-being. In the midst of this pandemic, voluntary sentinel and safety event reporting to the Joint Commission’s OQPS remains the same as before the pandemic, which further indicates that health care organizations are committed to providing safe, quality care.”
Patient safety specialists in OQPS help organizations to conduct a credible and thorough analysis of sentinel events to identify causative factors and implement relevant system solutions to prevent future harm.
“Earlier this year, OQPS introduced user-friendly safety event-specific templates that allow organizations to respond to requests from our office for written responses to safety events in a systematic manner,” Thomas stated. “These tools ensure that the specifics provided in the response are relevant to the type of event they are evaluating. Organizations have provided valuable positive feedback on these new templates, and we are committed to adding more tools to the repository of templates. As we develop and implement new tools, we will continue to seek input from healthcare organizations to ensure their value and usefulness.”
The summary data of sentinel event statistics for the first half of 2021 covers 16,695 incidents reported from 1995 through June 30, 2021.These events affected a total of 14,105 patients (as multiple patients may be affected by a single event):
- 47% of sentinel events led to a patient’s death.
- 24% led to unexpected additional care.
- 11% led to severe temporary harm.
- 6% led to permanent loss of function.
- 2% led to permanent harm.
- 2% led to a psychological impact.
An estimated fewer than 2% of all sentinel events are reported to The Joint Commission. 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.