Sentinel event statistics released for 2020
In 2020, The Joint Commission reviewed a total of 794 sentinel events.
The majority — 703 or 89% — were voluntarily self-reported by an accredited or
The most frequently reported sentinel events in 2020 were:
- Fall: 170
- Unintended retention of a foreign object: 106
- Suicide: 81
- Delay in treatment: 76
- Wrong-site surgery: 68
- Assault/rape/sexual assault: 47
- Fire: 30
- Clinical alarm response: 27
- Self-harm: 24
- Medication management: 24
Reporting of sentinel events by accredited organizations is voluntary, and it is estimated that less than 2% of all sentinel events that occur in health care are reported to The Joint Commission. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. The Office of Quality and Patient Safety at The Joint Commission works with organizations reporting sentinel events to identify contributing factors and actions the organization can take to reduce risk.
“As we work toward our goal of zero harm in health care, we should not lose focus on system thinking and continuous improvement while learning from close calls and strengthening the culture of safety at all levels in an organization,” said Raji Thomas, DNP, MBA, CPHQ, CPPS, Director, Office of Quality and Patient Safety, The Joint Commission. “Partnering with The Joint Commission’s Office of Quality and Patient Safety to review sentinel events allows our accredited organizations to work with a team of national experts in patient safety with a wide range of clinical and nonclinical backgrounds, including human factors engineering. This team has likely reviewed similar events from other organizations and will be able to share the valuable lessons from those events to improve safety in another organization during those reviews.”
Learn more about sentinel events or call the Office of Quality and Patient Safety at 630-792-3700.