© Copyright, The Joint Commission Sentinel Event Data Event Type by Year 1995-2012 Office of Quality Monitoring - 2 © Copyright, The Joint Commission Sentinel Event 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. Such events are called “sentinel” because they signal the need for immediate investigation and response. 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. http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/ Office of Quality Monitoring - 3 © Copyright, The Joint Commission 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-the- clock 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 . http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/ Office of Quality Monitoring - 4 © Copyright, The Joint Commission Data Limitations 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. Office of Quality Monitoring - 5 © Copyright, The Joint Commission Abduction Events Reviewed by The Joint Commission (Of any individual receiving care, treatment or services) 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 0 3 4 4 9 2 2 1 2 4 4 7 3 1 1 1 3 0 5 10 15 20 25 30 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Events Reviewed by TJC Sentinel Event Alert #9: "Infant Abductions" April 1999 Office of Quality Monitoring - 6 © Copyright, The Joint Commission Anesthesia-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 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 1 0 4 6 8 3 4 6 10 12 8 14 6 15 6 16 7 0 5 10 15 20 25 30 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Events Reviewed by TJC Sentinel Event Alert #32: "Anesthesia Awareness" October 2004 Office of Quality Monitoring - 7 © Copyright, The Joint Commission 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) 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 1 7 12 11 16 15 9 3 16 13 20 35 42 34 28 49 43 0 10 20 30 40 50 60 70 80 90 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Events Reviewed by TJC Sentinel Event Alert #45: "Preventing Violence in Healthcare Settings" June 2010 Office of Quality Monitoring - 8 © Copyright, The Joint Commission Delay in Treatment Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 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 3 7 18 18 35 26 36 37 50 54 42 78 103 123 95 138 107 0 20 40 60 80 100 120 140 160 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Events Reviewed by TJC Sentinel Event Alert #26: "Delay in Treatment" June 2002 Office of Quality Monitoring - 9 © Copyright, The Joint Commission Elopement-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 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 1 1 7 12 4 7 7 8 7 11 5 5 11 8 14 4 10 0 5 10 15 20 25 30 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Events Reviewed by TJC Office of Quality Monitoring - 10 © Copyright, The Joint Commission Fall-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 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 2 2 13 23 25 21 17 18 31 47 35 53 63 81 56 96 76 0 20 40 60 80 100 120 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Number of Events Reviewed by TJC Sentinel Event Alert #14: "Fatal Falls-Lessons for the Future" July 2000 [...]... 15 Sentinel Event Alert #18: "Kernicterus Threatens Health of Infants" April 2001 Sentinel Event Alert #31: "Revised Guidelines to Help Prevent Kernicterus" August 2004 10 Added to Sentinel Event Policy in 2005 5 1 0 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. .. relative frequency of events or trends in events over time 2011 0 2010 0 2009 2006 2005 2004 0 2008 0 2 2007 0 0 1 Office of Quality Monitoring - 12 © Copyright, The Joint Commission 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... 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 2007 2006 2005 2004 2001 2000 1999 1998 1996 1 0 1997 0 1995 0 14 2003 10 Sentinel Event Alert #22: "Preventing Needle... Commission 2 2000 1996 2 4 7 0 1998 0 1997 0 1995 0 3 3 4 6 2009 5 6 2008 7 1999 Number of Events Reviewed by TJC 30 Suicide Events Reviewed by The Joint Commission 140 Sentinel Event Alert #7: 120 "Inpatient Suicides: Recommendations for Prevention" 100 November 1998 80 Sentinel Event Alert #46: "A Follow-Up Report on Preventing Suicide" November 2010 71 85 67 53 55 49 40 87 63 58 60 103 Definition revised... 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 Office of Quality Monitoring - 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. .. 15 2002 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 10 6 4 8 3 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... relative frequency of events or trends in events over time 2008 2007 2006 2005 2002 2001 1997 2000 1996 3 4 7 0 1999 0 1998 0 1995 0 3 7 Office of Quality Monitoring - 14 © Copyright, The Joint Commission 5 4 2004 4 7 7 2003 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... 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 Office of Quality Monitoring - 17 © Copyright, The Joint Commission Number of Events Reviewed by TJC 90 Op/Post-op... 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 2012 31 2010 36 2011 31 2009 30 24 11 2003 14 19 2007 2006 2005 2004 The reporting of most sentinel events... 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 Office of Quality Monitoring - 20 © Copyright, The Joint Commission 10 2002 1997 13 16 1 1999 2 1998 0 1996 10 12 2001 10 2000 17 20 0 36 32 2008 40 1995 Number of Events Reviewed by TJC 90 Radiation Overdose Events Reviewed by . Commission Sentinel Event Data Event Type by Year 1995-2012 Office of Quality Monitoring - 2 © Copyright, The Joint Commission Sentinel Event A sentinel. of Events Reviewed by TJC Sentinel Event Alert #17: "Fires in the Home Care Setting" March 2001 Sentinel Event Alert # 29: "Preventing