Sentinel Event Data Event Type by Year 1995-2012 pdf

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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.

Office of Quality Monitoring - 3
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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
.

Office of Quality Monitoring - 4
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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
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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
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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
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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
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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
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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
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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
Office of Quality Monitoring - 11
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Fire-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 0
3

7
4
11
4
7
9
7
16
2
8
12
15
8
15 15
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
#17: "Fires in the
Home Care Setting"
March 2001
Sentinel Event Alert
# 29: "Preventing Surgical
Fires"
June 2003

Office of Quality Monitoring - 12
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Hyperbilirubinemia Events
Reviewed by The Joint Commission

(Bilirubin > 30 milligrams/deciliter)

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
1
0 0
0
2
1
0
0
5
10
15
20
25
30
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Added to Sentinel
Event Policy in 2005
Sentinel Event Alert
#18: "Kernicterus Threatens

Health of Infants"
April 2001
Sentinel Event Alert
#31: "Revised Guidelines to
Help Prevent Kernicterus"
August 2004
Office of Quality Monitoring - 13
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Infection-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 0
2
1
4
2
1
11
11
22
12
21
12 12
28

14
20
12
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
#22: "Preventing Needle
Stick & Sharp Injuries"
August 2001
Sentinel Event Alert
#28: "Infection Control Related
Sentinel Events"
January 2003
Office of Quality Monitoring - 14
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Inpatient Drug Overdose 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 0 0
4
3
4
4
7
3
4
7
6
7

3
7
8
19
22
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 - 15
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Maternal 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 0
3
5
3
6
5
4
9
10
15
12
10
5
13
16
18
8

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
# 44: "Preventing Maternal
Death"

January 2010
Office of Quality Monitoring - 16
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Medical Equipment-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 0
6
7
5
9
10
8
9
7
23
13
19
26
24
25
39
17
0

5
10
15
20
25
30
35
40
45
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 Alerts

# 15: "Infusion Pumps" November 2000
#21: "Medical Gas Mix-ups" July 2001
#36: "Tubing Misconnections" April 2006
#38: "MRI" February 2008
Office of Quality Monitoring - 17
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Medication Error 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
7
21
26
53
30
39
40
47
38
27
30
59
50
43

44
45
42
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 Alerts
#11: "High -alert meds" November1999
#16: "Mix -up leads to a Med Error" February
2001
#19: " Look-alike/sound-alike" May 2001
#23: "Abbreviations" September 2001
#35: "Medication reconciliation" January 2006
#39: "Pediatric med Errors" April 2008
#41: "Anticoagulants" September 2008
Office of Quality Monitoring - 18
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Op/Post-op Complication 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
9
28
58
62
51
70
48

53
75
49
75
71
94
86
133
83
0
20
40
60
80
100
120
140
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
#12: "Operative and Post-
Operative Complications"
February 2000
Office of Quality Monitoring - 19
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Other Unanticipated Events
Reviewed by The Joint Commission

(Resulting in death or permanent loss of function such as: asphyxiation,
choking, drowning, found unresponsive)

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
11
47
40
33
40
65

31
51
34
48
41
52
38
71
56
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
Office of Quality Monitoring - 20
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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)

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
1
10
17
12
13
10
11

14
24
16
19
32
31
31
36 36
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
#30: "Preventing Infant Death
& Injury in Delivery"
July 2004
Office of Quality Monitoring - 21
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Radiation Overdose Events
Reviewed by The Joint Commission

(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)

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
2
3
5
8

8
3
0
5
10
15
20
25
30
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Added to Sentinel
Event Policy in 2005
Office of Quality Monitoring - 22
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Restraint-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
6
14
16
26
25
18
12 12
17
14
23
13
11
5
15
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
#8: "Preventing
Restraint Deaths"
November 1998
Office of Quality Monitoring - 23
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Self-inflicted Injury Events
Reviewed by The Joint Commission

(Resulting in death or permanent loss of function not related to suicide)

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
0
3
2
2
4
2
3
7
4
1
4
6 6
7
6
14
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 - 24
© Copyright, The Joint Commission
Suicide Events
Reviewed by The Joint Commission

(Of any individual receiving care, treatment or services in a staffed
around-the-clock care setting or within 72 hours of discharge)

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
4
30
58

69
66
49
63
48
33
53
55
71
103
87
67
131
85
0
20
40
60
80
100
120
140
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
#7: "Inpatient Suicides:
Recommendations for
Prevention"
November 1998
Definition revised to
include suicide within
72 hours of discharge:
March 2005
Sentinel Event Alert
#46: "A Follow-Up Report on Preventing Suicide"
November 2010
Office of Quality Monitoring - 25
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Transfer-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
0
3 3
2
3
1 1
0
1
2
1
2
3
2
3
7
2
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