Joint Commission counted 887 sentinel events in 2013

Among the 887 sentinel events the Joint Commission recorded last year, the top three were delays in treatment that resulted in death or permanent disability; wrong-site, wrong-patient or wrong-procedure mistakes; and unintended retention of a foreign object after a procedure.

The Joint Commission learns of sentinel events either voluntarily from accredited organizations, or through complaints or media coverage. It estimates that out of all sentinel events each year, it only learns about 2 percent of incidents.

Because of this, the Joint Commission does not attempt to create a sentinel event rate by comparing its count of incidents with the total number of procedures and hospitalizations each year. Event counts by year therefore cannot be compared, other than to note that the same types of errors tend to be the most counted year after year.

In 2013, the Joint Commission counted 113 treatment delays that resulted in death or permanent loss of function. This was up from 2012, when the Commission counted 107 such events, but down from the 138 such events it counted in 2011.

The serious procedure mistake category of wrong-site, wrong-patient or wrong-procedure numbered 109, the same amount counted in 2012.

The retention of an unintended foreign object occurred in 102 procedures. This was 13 fewer incidents than what the Commission counted in 2012 and the lowest number since 2008.

Since the Joint Commission began counting sentinel events in 2004, a total of 7,881 patients have been effected, with just over half of incidents (59.1 percent) resulting in a patient’s death. Learn more on its website.