Sentinel Event Data General Information 1995 2015
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 - 2
Adverse Event Reporting States WASHINGTON MONTANA NORTH DAKOTA MINNESOTA MICHIGAN VERMONT MAINE OREGON CALIFORNIA NEVADA IDAHO UTAH WYOMING COLORADO COLORADO SOUTH DAKOTA NEBRASKA KANSAS IOWA WISCONSIN MISSOURI INDIANA ILLINOIS OHIO NEW YORK PENNSYLVANIA WEST VIRGINIA VIRGINIA KENTUCKY RHODE ISLAND CONNECTICUT NEW JERSEY DELAWARE MARYLAND NEW HAMPSHIRE MASSACHUSETTS District of Columbia ARIZONA NEW MEXICO OKLAHOMA ARKANSAS TENNESSEE NORTH CAROLINA SOUTH CAROLINA PUERTO RICO HAWAII ALASKA TEXAS LOUISIANA MISSISSIPPI GEORGIA ALABAMA 26 States + D.C. The r reporting of events to The Joint Commission is a voluntary process, and represents only a small proportion of actual events. Therefore, this information should not be viewed as reflecting an epidemiologic data set and no conclusions should be drawn about the actual relative FLORIDA Office of Quality Monitoring - 3
Sources of Reported Reviewable Sentinel Events 2004 through 2015 www.jointcommission.org/report_a_complaint.aspx Self Reported Media Other 1400 Number of Events Reviewed by TJC 1200 1000 800 600 400 200 0 2004 2005 2006 2007 2008 2009 2010 2011 represents only a small proportion of actual events. Therefore, these data are not an 2015 2014 2013 2012 Office of Quality Monitoring - 4
Settings of Sentinel Events Reviewed by The Joint Commission 2004 through 2015 0% 10% 20% 30% 40% 50% 60% 70% 80% Hospital Psychiatric hospital Ambulatory care Psych unit in general hospital Emergency department Behavioral health facility Home care Other*** Long term care facility Office-based surgery 2% 1% 1% 1% 4% 5% 4% 10% 5% represents only a small proportion of actual events. Therefore, these data are not an 67% ***Other includes: Disease specific care, Diagnostic imaging, Hospice care Office of Quality Monitoring - 5
Total Reported Sentinel Events by Year 1995 through 2015 Number of Reviewable Events Reported 1400 1200 1000 800 600 400 200 0 1 1995 46 1996 122 1997 284 1998 401 1999 449 2000 429 2001 460 2002 545 550 607 2003 2004 2005 691 2006 790 2007 represents only a small proportion of actual events. Therefore, these data are not an 927 938 920 2008 2009 2010 1243 2011 901 887 2012 2013 764 2014 936 2015 Office of Quality Monitoring - 6
Most Frequently Reviewed Sentinel Event Categories by Year 2013 2014 2015 Delay In Treatment Wrong-patient, wrong-site, wrong-procedure Unintended Retention of a Foreign Body Unintended Retention of a Foreign Body Fall Suicide Wrong-patient, wrong-site, wrong-procedure Unintended Retention of a Foreign Body Suicide Suicide Other Unanticipated Event* Fall Fall Delay In Treatment Delay In Treatment Other Unanticipated Event* Wrong-patient, wrong-site, wrong-procedure Op/Post-op Complication Op/Post-op Complication Op/Post-op Complication Other Unanticipated Event* Criminal Event Criminal Event Criminal Event Medication Error Perinatal Death/Injury Perinatal Death/Injury Perinatal Death/Injury Medication Error Medication Error *Other includes: Unexpected Additional Care/Extended Care, and Psychological Impact represents only a small proportion of actual events. Therefore these data are not an Office of Quality Monitoring - 7
RCA Review Methods Selected by Accredited Health Care Organizations 2015 RCA shared with Joint Commission using other methods 12% RCA shared with Joint Commission via web conference 17% RCA submitted to Joint Commission electronically 71% represents only a small proportion of actual events. Therefore, these data are not an Office of Quality Monitoring - 8