Numbers show most reports from media
Inpatient suicides lead the statistics
At the recent meeting of the American Society for Healthcare Risk Management in San Diego, a representative presented some of the latest statistics from the Joint Commission on the Accreditation of Healthcare Organizations’ sentinel events program. These are highlights presented by Donna Nowakowski, RN, director of government relations and external affairs for the Joint Commission:
There have been 332 sentinel events investigated by the Joint Commission to date, and of that number, Nowakowski had statistics for 287. The largest number of incidents, 57, were inpatient suicides, followed by 49 medication errors, 23 deaths related to a delay in treatment, 21 operative or postoperative complications, 20 deaths of patients in restraints, 17 events of surgery at the wrong site, 12 incidents of physical assault (including rape) or homicide, 11 transfusion-related deaths, 10 infant abductions or wrong discharges, six multistory patient falls, and five events involving medical gas systems.
The Joint Commission became aware of 41% of the incidents through the media, the most common way events were discovered, confirming the view of some skeptics that the sentinel event policy just plays on the sensational accidents reported by the news media. Another 29% were self-reported, but Nowakowski says the next update of the statistics probably will show that media reports and self-reports now account for close to equal portions of sentinel events because providers are more proactive in reporting their own events.
Twenty-one percent were discovered during a Joint Commission survey, 2% were reported by the patient or a family member, and 1% by an employee of the provider. Five percent were reported by some other method, such as a government agency or an anonymous report.
As some would expect, about 60% of the events occurred in a general hospital setting, followed by 22% in a psychiatric hospital, 8% in a psychiatric unit, 4% in an emergency department, 2% in an outpatient behavioral health center, 2% in a home care service, 1% in a long-term care facility, 1% in an ambulatory care setting, and 0.3% (one incident) in a clinical laboratory.
In the 287 incidents, a total of 334 patients were affected and there were 269 deaths. There was major loss of function in 14 incidents. Orientation and training deficiencies were identified as the root cause in most analyses, followed by communication and the patient assessment process.