The Joint Commission offers a five-step process of what to do next.

Facing a Sentinel Event Head-on (What to Do When an Event Occurs) Note: An estimated fewer than 2% of all sentinel events are reported to The Joint Commission.

47% of sentinel events led to a patient’s death.

Source: The Joint Commission, Sentinel event data released for the first six months of 2021 These events affected a total of 14,105 patients (as multiple patients may be affected by a single event): Sentinel Events Led To.

Sentinel event statistics for the first half of 2021 covers 16,695 incidents reported from 1995 through June 30, 2021. The remaining 53 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization. The majority of events-516 total or 91%-were self-reported by an accredited or certified organization. Through the first six months of 2021, The Joint Commission reviewed 569 sentinel events. Most Frequently Reported Sentinel Events (1st Half of 2021 Statistics) Falls include any fall whether it occurred at home, out in the community, in an acute hospital, or ambulatory setting.' - The Joint Commission, Does the Joint Commission provide an official definition of a patient 'fall' or does each organization need to define it? The fall may be witnessed, reported by a patient, an observer, or identified when the patient is found on the floor or ground. 'A fall may be described as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface (e.g., onto a bed, chair, or bedside mat). Others include delay in treatment, medication error, and fire-related events.įalls resulting in injury are a prevalent safety problem. This could include the failure of room outlets to provide oxygen or failure of inlets to provide sufficient vacuum to a patient.Īccording to the Joint Commission, the most common cause of sentinel events in healthcare includes unintended retention of a foreign object, fall-related events, and performing procedures on the wrong patient.

Permanent harm: An event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline.įrom a facility's perspective, an example of a sentinel event could be a fall event or the failure of some equipment that is part of the regular building function.

Severe harm: An event or condition that reaches the individual, resulting in life-threatening bodily injury (including pain or disfigurement) that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring or a surgery, invasive procedure, or treatment to resolve the condition.

Sentinel event: A patient safety event (not primarily related to the natural course of the illness or underlying condition) that reaches a and results in death, severe harm (regardless of the duration of harm), or permanent harm (regardless of the severity of harm).

OQPS revised the definition to clarify the differences between severe harm (which may or may not be permanent) and permanent harm (regardless of severity). 1, 2022, The Joint Commission’s Office of Quality and Patient Safety (OQPS) revised its definition of a sentinel event and clarified some of the event-specific examples in the Sentinel Event Policy.

The events are named 'sentinel' because they signal the need for immediate investigation and response.Īs of Jan. Because of the airflow standards, equipment must meet high ventilation rates and filtration requirements. In addition, one of the requirements and concerns as a healthcare facility manager is the ventilation in your care areas. We understand the contributing factors and actions facilities can take to reduce the risk of these events.īased on our experience, we thought we would address sentinel events with examples, statistics, and a 5-step process of what to do when and if a sentinel event occurs in your facility. Sentinel events are debilitating to both patients and healthcare providers involved in the event. The Joint Commission works closely with organizations to address sentinel events and to prevent them from occurring in the first place.ĬHT is a national leader providing support to healthcare facilities in identifying and developing compliance programs regarding their medical gas needs and environmental monitoring to protect patients and employees. Sentinel events occur when a patient is seriously injured (permanently or temporary) or causes death, happening outside the predictable course of the patient’s disease process.