10 most common adverse events reviewed by the Joint Commission

The Joint Commission has updated its list of the most common sentinel events at accredited facilities it reviewed in 2017, which set a record for the highest percentage of such events being self-reported by providers.

Sentinel events are serious adverse incidents which result in a patient dying or suffering a serious physical or psychological injury. Last year, the Joint Commission reviewed reports of 805 such events—700 of which (87 percent) were voluntarily reported by accredited or certified facility.

The top most frequently reported events were:

  1. Unintended retention of a foreign body: 116
  2. Fall: 114
  3. Wrong patient, wrong site, wrong procedure events: 95
  4. Suicide: 89
  5. Delay in treatment: 66
  6. Other unanticipated event (which could include a patient being burned, choking on food or being found unresponsive): 60
  7. Criminal event: 37
  8. Medication error: 32
  9. Operative or post-op complication: 19
  10. Self-inflected injury: 18

The biggest change amongst any particular event was for operative or post-op complications, which fell from 82 reported events in 2015 and 50 reported events in 2016 to 19 last year. The final tally may change, however, as 54 reported events remained unclassified at the time of the report.

In cumulative statistics collected between 2005 and 2017, the Joint Commission said nearly 11,200 patients have impacted by reported sentinel events. The most common outcome for those patients was death, being reported for 52.1 percent (5,826) of the impacted patients, followed by unexpected additional care (25.7 percent or 2,881 patients).