Joint Commission 2017 Sentinel Event Statistics
The Joint Commission (TJC) recently released updated sentinel event statistics for 2017. A total of 805 reported sentinel events were reviewed in 2017; the top three most often reported sentinel events were:
- Unintended retention of a foreign body (116)
- Falls (114)
- Wrong-patient, wrong-site, wrong-procedure (95)
Joint Commission defines a Sentinel Event as “a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following: death, permanent harm, severe temporary harm. Sentinel events have a high potential to reflect serious underlying “systems” related problems within an organization and therefore it is important for organizations to identify the causes, trends, settings and outcomes of these events.
When an organization experiences a Sentinel Event, a root cause analysis should be conducted. The root cause analysis focuses on systems and processes, not individual performance. The idea is to uncover the systemic contributors to an event. The goals of a root cause analysis include:
- Identifying the causative issues, systems or processes that represent core reasons for occurrence of the event.
- Developing an action plan that will prevent recurrence of the event.
- Implementing the action plan, monitoring the plan’s effectiveness periodically.
- Assuring the event will not be repeated.
Included with today’s notice are example policies related to Sentinel Events and conducting a root cause analysis. Upcoming StayAlert! Notices will review specific sentinel events.
Want to read the full alert and receive alert emails?