Sentinel Event Data Event Type by Year 199-12
Sentinel Event http://www.jointcommission.org/sentinel_event_policy_and_procedures/ 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. Office of Quality Monitoring - 2
. Reviewable Sentinel Events http://www.jointcommission.org/sentinel_event_policy_and_procedures/ 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-theclock care setting or within 2 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 > miligrams/deciliter) Prolonged fluoroscopy with cumulative dose > rads to a single field or any delivery of radiotherapy to the wrong body region or >% above the planned radiotherapy dose Office of Quality Monitoring -
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 - 4
Abduction Events (Of any individual receiving care, treatment or services) 199 #9: "Infant Abductions" April 4 4 9 2 2 1 2 1 2 4 4 4 6 1 1 1 12 11 9 8 Office of Quality Monitoring -
Anesthesia-related Events (Resulting in death or permanent loss of function) 199 1 #2: "Anesthesia Awareness" October 4 4 6 8 1 4 2 6 4 12 8 6 16 14 6 6 12 11 9 8 Office of Quality Monitoring - 6
Criminal Events -- Assault/Rape/Homicide (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) 9 8 6 4 1 199 12 11 16 1 9 2 #4: "Preventing Violence in Healthcare Settings" June 16 4 1 6 42 8 4 9 28 49 11 4 12 Office of Quality Monitoring -
Delay in Treatment Events (Resulting in death or permanent loss of function) 16 14 1 8 6 4 1 199 18 18 #26: "Delay in Treatment" June 2 26 1 6 2 4 4 42 6 18 12 9 8 12 11 9 8 Office of Quality Monitoring - 8
Elopement-related Events (Resulting in death or permanent loss of function) 199 1 1 12 4 1 2 8 4 11 6 11 8 8 9 14 Office of Quality Monitoring - 9 4 11 12
Fall-related Events (Resulting in death or permanent loss of function) 1 8 6 4 2 2 199 #14: "Fatal Falls-Lessons for the Future" July 1 2 21 1 1 18 2 1 4 4 6 96 81 6 6 6 12 11 9 8 Office of Quality Monitoring -
Fire-related Events (Resulting in death or permanent loss of function) 199 #1: "Fires in the Home Care Setting" March 1 4 11 4 1 2 # 29: "Preventing Surgical Fires" June 9 4 16 2 6 8 12 8 9 8 11 12 Office of Quality Monitoring - 11
Hyperbilirubinemia Events (Bilirubin > milligrams/deciliter) #18: "Kernicterus Threatens Health of Infants" April 1 #1: "Revised Guidelines to Help Prevent Kernicterus" August 4 4 1 6 Added to Sentinel Event Policy in 8 9 2 1 12 11 Office of Quality Monitoring - 12
Infection-related Events (Resulting in death or permanent loss of function) 28 199 #28: "Infection Control Related Sentinel Events" January #22: "Preventing Needle Stick & Sharp Injuries" August 1 2 1 4 2 1 1 11 11 2 22 4 12 21 6 12 12 8 9 14 11 12 12 Office of Quality Monitoring - 1
Inpatient Drug Overdose Events (Resulting in death or permanent loss of function) 199 4 4 4 1 2 4 4 6 6 8 9 8 19 11 22 12 Office of Quality Monitoring - 14
Maternal Events (Resulting in death or permanent loss of function) 199 6 4 1 2 9 4 # 44: "Preventing Maternal Death" January 12 6 8 1 9 16 18 11 Office of Quality Monitoring - 8 12
Medical Equipment-related Events (Resulting in death or permanent loss of function) 4 4 199 s # : "Infusion Pumps" November #21: "Medical Gas Mix-ups" July 1 #6: "Tubing Misconnections" April 6 #8: "MRI" February 8 6 9 1 8 9 2 4 2 1 6 19 26 8 24 9 9 11 1 12 Office of Quality Monitoring - 16
Medication Error Events (Resulting in death or permanent loss of function) 9 8 6 4 s #11: "High -alert meds" November #16: "Mix -up leads to a Med Error" February 1 #19: " Look-alike/sound-alike" May 1 199 21 26 9 1 4 2 4 8 2 #2: "Abbreviations" September 1 #: "Medication reconciliation" January 6 #9: "Pediatric med Errors" April 8 #41: "Anticoagulants" September 8 4 6 9 8 4 44 4 9 11 42 12 Office of Quality Monitoring - 1
Op/Post-op Complication Events (Resulting in death or permanent loss of function) 14 1 8 6 4 1 199 #12: "Operative and Post- Operative Complications" February 9 28 8 62 1 1 2 48 4 49 6 1 8 94 9 86 1 11 8 12 Office of Quality Monitoring - 18
Other Unanticipated Events (Resulting in death or permanent loss of function--such as: asphyxiation, choking, drowning, found unresponsive) 9 8 6 4 1 1 199 11 4 4 1 4 2 6 1 4 1 4 6 48 41 8 2 9 8 1 11 6 12 Office of Quality Monitoring - 19
Perinatal Events (Resulting in death or permanent loss of function--full-term infant g or > and absence of obvious congenital abnormality) 9 8 6 4 199 2 1 1 #: "Preventing Infant Death & Injury in Delivery" July 4 12 1 1 11 2 14 4 24 16 6 6 6 2 1 1 19 12 11 9 8 Office of Quality Monitoring -
Radiation Overdose Events (Cumulative dose > rads to a single field, or any delivery of radiotherapy to the wrong body region or > % above the planned radiotherapy dose) Added to Sentinel Event Policy in 1 2 6 8 9 11 12 8 8 Office of Quality Monitoring - 21
Restraint-related Events (Resulting in death or permanent loss of function) Sentinel Event Alert #8: "Preventing Restraint Deaths" November 199 2 6 14 16 26 1 18 2 12 12 4 1 14 6 2 1 8 11 9 11 Office of Quality Monitoring - 22 12
Self-inflicted Injury Events (Resulting in death or permanent loss of function--not related to suicide) 199 2 2 4 1 2 2 4 4 1 6 4 6 6 8 9 Office of Quality Monitoring - 2 6 11 14 12
Suicide Events (Of any individual receiving care, treatment or services in a staffed around-the-clock care setting or within 2 hours of discharge) 14 1 #: "Inpatient Suicides: Recommendations for Prevention" November 8 6 4 199 4 8 69 #46: "A Follow-Up Report on Preventing Suicide" November 66 Definition revised to include suicide within 2 hours of discharge: March 49 1 6 2 48 4 6 1 8 8 9 6 11 11 8 12 Office of Quality Monitoring - 24
Transfer-related Events (Resulting in death or permanent loss of function) 199 2 1 1 1 2 1 4 2 1 2 6 8 2 9 Office of Quality Monitoring - 11 2 12
Transfusion-related Events (Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities) 199 # : " Preventing Future Occurrences" August 1 6 11 6 18 1 14 2 1 4 6 6 19 16 1 12 12 11 9 8 Office of Quality Monitoring - 26
Unintended Retention of Foreign Object Events 18 16 14 1 8 6 4 1 Added to SE Policy June 6 8 8 119 9 1 188 11 1 12 Office of Quality Monitoring - 2
Ventilator-related Events (Resulting in death or permanent loss of function) 199 2 1 #: "Preventing Ventilator Deaths & Injuries" February 2 4 4 1 2 1 4 6 2 4 8 6 6 9 8 11 Office of Quality Monitoring - 28 12
Wrong-patient, Wrong-site, Wrong-procedure Events 16 14 1 8 6 4 "Follow-up Review of Wrong Site Surgery" December 1 #6: "Wrong-Site Surgery" August 2 199 (Regardless of the magnitude of the procedure) 26 4 NPSGs: January Wrong Site Surgery Summit I May 6 6 1 6 2 4 Universal Protocol 4 9 Wrong Site Surgery Summit II February 6 94 116 8 9 149 9 2 Wrong Site Surgery Definition Revised June 11 Office of Quality Monitoring - 29 9 12