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Joint Commission updates sentinel event statistics

The Joint Commission has updated its website with its latest sentinel event statistics. As of September 30, 2010, the sentinel event database has record of 7,147  sentinel events reviewed by The Joint Commission since its implementation in January 2005. All events were voluntarily reported by Joint Commission accredited organizations, and represent only a small proportion of actual events.

According to the organization’s statistics, the top ten sentinel events submitted to The Joint Commission over the past 15.5 years are:

  1. Wrong-site surgery: 956
  2. Suicide: 832
  3. Operative/post-operative complication: 775
  4. Delay in treatment: 611
  5. Medication error: 563
  6. Patient fall: 461
  7. Unintended retention of foreign body: 421
  8. Assault, rape, or homicide: 270
  9. Perinatal death or loss of function: 229
  10. Patient death or injury in restraints: 204

A total of 7,288 patients were affected by these events, with 4,844 resulting in patient death.

Click here to view more statistics.

Joint Commission releases Sentinel Event Alert

The latest Sentinel Event Alert was released by The Joint Commission this morning urging healthcare leaders to become more involved in the prevention of medical errors at their facilities, as well as to take more responsibility when errors do occur. The alert, titled “Leadership committed to safety,” reflects many of the changes made to the leadership chapter in The Joint Commission’s 2009 Comprehensive Accreditation Manual for Hospitals (which contains the standards hospitals need to comply with to attain accreditation by The Joint Commission.)

The alert asks leaders to recognize that if there is a failure of some sort in the organization, no matter the result, they are ultimately responsible, and acknowledging that will go a long way toward fixing those errors. Additionally, building a culture of safety is part of preventing medical errors and is something that can only truly happen when leaders buy-in and show that that doing so is not just something they are preaching–it is something they live every single day.

The alert gives some recommendations to leaders. One of these is creating a transparent environment that encourages reporting of near miss events and allows staff members to talk freely about the facility’s trouble spots without being penalized. Similar to this, one recommendation is to support staff members who are involved in a medical error by recognizing that errors are most often the result of system failures, rather than assigning blame to one or two people involved. Allowing involved staff members to participate in the route cause analysis and investigation will help prevent future errors. However, the alert also recommends that leaders recognize the need to create a functioning disciplinary policy for those staff members who exhibit specific, defined behaviors.

You can read the full list of recommendations, as well as the Sentinel Event Alert here.

New Sentinel Event posted

Hello, everyone. The Joint Commission has released its latest Sentinel Event Alert, this time on errors related to the use of technology in the healthcare setting.

The Alert states that there is very little data documenting the frequency with which technology-related errors occur, but notes that computers and automated medication dispensing devices are frequently involved when an error occurs. The Alert also advocates using Joint Commission Information Management standards to improve the use of technology in the healthcare environment.

The Joint Commission suggests 13 steps to prevent healthcare technology errors, including training for new users and refresher courses for those who continue to use technology in the hospital, and clearly defining who is authorized and responsible for the technology. Their complete press release and additional information can be found here.