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The Joint Commission Releases Sentinel Event Data on Serious Adverse Events at U.S. Healthcare Organizations

Data on sentinel events reviewed Jan. 1 through Dec. 31, 2022 Tuesday, April 4, 2023

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Katie Bronk
Corporate Communications
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(OAKBROOK TERRACE, Illinois, April 4, 2023) – The Joint Commission has released its Sentinel Event Data 2022 Annual Review on serious adverse events from Jan. 1 through Dec. 31, 2022. A sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm. Sentinel events are debilitating to both patients and healthcare providers involved in the event.

The Joint Commission reviewed 1,441 sentinel events in 2022. The most prevalent sentinel event types were: 

  • Falls (42%)
  • Delay in treatment (6%)
  • Unintended retention of foreign object (6%)
  • Wrong surgery (6%)
  • Suicide (5%)

Failures in communications, teamwork and consistently following polices were the leading causes for reported sentinel events. Most reported sentinel events occurred in a hospital (88%). Of all the sentinel events, 20% were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional care/extended stay.

“COVID-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” notes Haytham Kaafarani, MD, MPH, FACS, chief patient safety officer and medical director, The Joint Commission. “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. Our goal is to help prevent these types of adverse events from occurring again.”

The majority of sentinel events (90%) were voluntarily self-reported to The Joint Commission by an accredited or certified healthcare organization. The remaining sentinel events were reported either by patients or their families, or employees of a healthcare organization.

Reporting of sentinel events to The Joint Commission is a voluntary process, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

The full sentinel event data summary is available on The Joint Commission website. 

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About The Joint Commission

Founded in 1951, The Joint Commission seeks to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare. Learn more about The Joint Commission at www.jointcommission.org.

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