Sentinel Events in Hospitals Continue To Rise

The number of sentinel events in hospitals in the United States increased by 19% from 2021 to 2022, on the basis of new data from The Joint Commission.

Reporting sentinel events to The Joint Commission began in 1996 as a way to help healthcare organizations improve safety. The annual review is based on an aggregate database of reports analyzed each year, according to the review authors.

The Joint Commission defines a sentinel event as a patient safety event that reaches a patient and results in death, permanent harm (regardless of severity), or severe harm (regardless of duration).

Some of the specific events deemed sentinel include patient suicide while under care in a healthcare setting, unanticipated death of a full-term infant, homicide of any patient or staff member while on site at a healthcare organization, any intrapartum maternal death, severe maternal morbidity, sexual abuse or assault of any patient undergoing care in the healthcare setting, sexual abuse or assault of any staff member providing care, and physical assault of any patient or staff member in the healthcare setting.

Additional events considered sentinel are related to treatments and procedures. These include surgery in the wrong site; wrong patient or wrong procedure for a given patient; administration of blood or blood products incompatible with the patient that results in death, permanent harm, or severe harm; severe neonatal hyperbilirubinemia; and patient falls.

A total of 1441 sentinel events were reported in 2022. Patient falls accounted for the majority (42%) of these events, continuing a trend in increasing rates of patient falls from previous years. Falls considered sentinel events were those resulting in any fracture, surgery, casting, or traction, consultation or comfort care for neurologic or internal injury, the need for blood products, or death or permanent harm as a result of injuries sustained in the fall. The leading sentinel event types after falls included delay in treatment, unintended retention of a foreign object, and wrong surgery (6% for each). Other sentinel event types in the top 10 accounted for 5% or less of reports: suicide (5%), assault/rape/sexual assault/homicide (4%), fire/burns (3%), perinatal events (2%), self-harm (2%), and medication management (2%).

Overall, 20% of the 2022 events resulted in patient death, 6% in permanent harm or loss of function, 44% in severe temporary harm, and 13% in a need for additional care or an extended hospital stay.

The most common events the led to patient death were suicide (24%), treatment delays (21%), and patient falls (11%). Patient falls also accounted for nearly two thirds of the events resulting in severe temporary harm (62%).

Most of the events (88%) occurred in hospital settings; of these, the most common were falls (45%) followed by the retention of foreign objects and incorrect surgeries (7% and 6%, respectively). Overall, 90% of sentinel events were reported by the healthcare organizations; the remaining 10% were reported by patients, families, or employees (current or former).

“Failures in communication, teamwork and consistently following policies were leading causes for reported sentinel events,” the authors wrote. However, reporting sentinel events is voluntary; therefore “no conclusions should be drawn about the actual relative frequency of events or trends in events over time,” they noted.

Increased Reporting May Not Reflect Increased Occurrence

“It is important to clarify that The Joint Commission saw an increase in reporting of sentinel events; whether this is indicative of an actual increase in occurrence of sentinel events across the country or not is difficult to say, as the reporting is voluntary,” said Haytham Kaafarani, MD, MPH, chief patient safety officer and medical director for The Joint Commission, in an interview.

“However, this is the highest number reported to The Joint Commission since the inception of the sentinel event policy: there were 547 healthcare organizations that reported sentinel events in 2022, compared to 500 in 2021 and 423 in 2020,” Kaafarani said. “Having said that, based on published literature, the COVID-19 pandemic stressed our healthcare systems in many ways including but not limited to: staff shortage in times of increased needs, worsening of mental health conditions, and delay in presentation of non-COVID related medical conditions during the pandemic,” he noted.

Kaafarani said that The Joint Commission was not surprised by the type of sentinel events reported, which has remained consistent with previous years.

“However, The Joint Commission was surprised by the significant increase in the number of reported events, he said. “Since reporting is voluntarily, we welcome the increase in reporting of sentinel events, as it helps The Joint Commission better understand the patient safety landscape across the country, and better helps healthcare organizations during their difficult times.”

Published literature suggests that the COVID-19 pandemic may have contributed to the increase in reporting sentinel events, Kaafarani said. The pandemic stressed the healthcare system in ways such as staff shortages in times of increased needs, worsening of mental health conditions, and delays in presentation of non-COVID medical conditions, he said.

“The Joint Commission defines a sentinel event as a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm (regardless of severity of harm), or severe harm (regardless of duration of harm),” Kaafarani said. “Sentinel events happen within every healthcare organization, albeit infrequently,” he added.

“Reporting sentinel events to The Joint Commission allows for a better understanding of the current safety issues across all healthcare organizations which can help to direct healthcare policy,” he said. “It also permits The Joint Commission to assist healthcare organizations examine the root cause of these rare events in order to prevent them.”

Based on the latest information, “The Joint Commission encourages healthcare organizations to create research that is focused on preventing patient falls in hospitals,” said Kaafarani. “With staff shortages reported within many healthcare organizations, it is now more essential than ever to establish systematic interventions to prevent patient falls and resultant harm.”