ED Accreditation Update: Delayed treatment causes most sentinel events in ED

Delay in treatment remains the most common cause of sentinel events in EDs, accounting for more than half of all sentinel events originating in EDs since the Joint Commission on Accreditation of Healthcare Organizations began tracking the events in 1995.

In order of frequency, the top five most common sentinel events in EDs were: delay in treatment (50 cases, 51.5% of the total); medication error (12, 12.4%); suicide (9, 9.3%); restraint-related events (4, 4.1%); and assault, rape, or homicide (3, 3.1%).

Figures for hospitalwide sentinel events indicate that, counting sentinel events from all departments, delay in treatment accounted for 5% of all sentinel events in hospitals as of mid-December 2003, when the figures were released by the Joint Commission. Hospitalwide, postoperative complications are the most common sentinel events.

Communication remains the predominant root cause of delay in treatment sentinel events, accounting for nearly 85% of delays in treatment, reporting hospitals told the Joint Commission.

Other root causes of delayed treatment, in order of predominance, included patient assessment (75%), continuum of care (62%), availability of information (42%), competency/credentialing (29%), orientation and training (29%), staffing levels (25%), specialist availability (16%), and ED overcrowding (16%). Agencies reported more than one root cause for most sentinel events.