TJC 2018 Sentinel Event Statistics
The Joint Commission has released 2018 Sentinel Event statistics. According to TJC, a total of 801 reported sentinel events were reviewed in 2018; 87% of those events being voluntarily self-reported by an accredited or certified organization.
The top three most often reported sentinel events in 2018 were:
- Unintended retention of a foreign body (111)
- Falls (111)
- Wrong-patient, wrong-site, wrong-procedure (94)
Sentinel events are “patient safety events (not primarily related to the natural course of the patient’s illness or underlying condition) that reach a patient and result in any of the following: death, permanent harm, severe temporary harm.”
There is often a correlation between a sentinel event and a serious underlying “system-related” problem within an organization. In addition to reporting such events to TJC, it is important for organizations to identify the causes, trends, settings and outcomes of these events.
When a sentinel event occurs in an organization, a root cause analysis should be conducted. By focusing on systems and processes, rather than individual performance, the systemic contributors to an event can be identified and addressed. The goals of a root cause analysis include:
- Identify the causative issues, systems or processes that represent core reasons for occurrence of the event.
- Develop an action plan that will prevent recurrence of the event.
- Implement the action plan, monitoring the plan’s effectiveness periodically.
- Assure the event will not be repeated
Included with today’s notice are example policies related to sentinel events and conducting root cause analysis. Upcoming StayAlert! Notices will review 2018’s most frequently reported sentinel events.
Want to read the full alert and receive alert emails?