10 most common sentinel events in 2023: Joint Commission

In 2023, patient falls were once again the most common sentinel event reported by healthcare organizations, according to a May 15 report from The Joint Commission.

The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, severe temporary harm or intervention required to sustain life.

The accrediting body received 1,411 reports of sentinel events in 2023, on par with the volume reported in 2022. Only a small portion of all sentinel events are reported to The Joint Commission, meaning conclusions about the events' frequency and long-term trends should not be drawn from the dataset, the organization said.

In total, 96% of healthcare organizations voluntarily reported sentinel events. About 18% of events were associated with patient death, 8% with permanent harm or loss of function, 57% with severe temporary harm and 12% with unexpected additional care or extended healthcare stays.

"As with previous years, failures in communication, teamwork and consistently
following policies were leading causes for reported sentinel events," The Joint Commission said.

The 10 most frequently reported sentinel events for 2023:

1. Falls — 48%
2. Wrong surgery — 8%
3. Unintended retention of foreign object — 8%
4. Assault/rape/sexual assault/homicide — 8%
5. Delay in treatment — 6%
6. Suicide — 5%
7. Fire/burns — 4%
8. Medication management — 2%
9. Perinatal event — 2%
10. Self-harm — 2%

View the full report here.

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