Adverse events rose 19% in 2022, Joint Commission finds

New data from The Joint Commission found that of all reported sentinel events in 2022, 44 percent resulted in severe temporary harm and 20 percent resulted in a patient death.

The Joint Commission defines a sentinel event as a patient safety event that reaches a patient and results in death, permanent harm or severe harm.

There were 1,441 reports of sentinel events in 2022, up by 19 percent from 2021, according to the report. The increase is above pre-pandemic levels, according to the April 4 news release. The top ten categories of sentinel events were:

  1. Falls — 42 percent
  2. Delay in treatment — 6 percent
  3. Foreign object retention — 6 percent
  4. Undergoing the incorrect surgery — 6 percent
  5. Suicide — 5 percent
  6. Assault/rape/sexual assault/homicide — 4 percent
  7. Fire/burns — 3 percent
  8. Perinatal event — 2 percent
  9. Self-harm — 2 percent
  10. Medication management — 2 percent

Sentinel event data reporting to The Joint Commission is a policy that was established in 1996 to improve patient safety. Hospitals, healthcare professionals, and even patients and families can report instances of these occurrences to the Commission, and that data is then aggregated and analyzed on an annual basis. 

The Joint Commission's report found that the most common causes of these adverse events that result in harmful outcomes are failures in communications, failures in teamwork and failures in consistently following policies.

"For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies," Haytham Kaafarani, MD, the chief patient safety officer and medical director for The Joint Commission, said in a statement. "Our goal is to help prevent these types of adverse events from occurring again."

However, because reporting sentinel events is a voluntary process, The Joint Commission notes that drawing any conclusions about trends over time from the data should be avoided.

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