Sentinel Event data released for 2021
New sentinel event data has been released by The Joint Commission to help accredited organizations mitigate and prevent future harm to care recipients. The Joint Commission reviewed 1,197 sentinel events in 2021, with the majority of these — 89% (1,068) — being voluntarily self-reported by an accredited or certified entity. The remaining 129 sentinel events were reported either by patients (or their families) or employees (current or former) of the organization.
Patient safety specialists in the Office of Quality and Patient Safety help organizations to conduct a credible and thorough analysis of sentinel events to identify causative factors and implement relevant system solutions to prevent future harm.
In 2021, the most frequently reported sentinel event category was care management events — with patient falls being the single largest reported harm events. The Top 10 most frequently reported sentinel events in 2021 were:
- Fall — 485
- Delay in treatment — 97
- Unintended retention of a foreign object — 97
- Wrong-site surgery — 85
- Suicide — 79
- Self-harm — 45
- Fire — 38
- Medication management — 35
- Assault — 34
- Clinical alarm response — 22
The summary data of sentinel event statistics covers 18,018 incidents reported from 1995 through Dec. 31, 2021. These events affected a total of 14,731 patients (as multiple patients may be affected by a single event):
- 46% of sentinel events led to a patient’s death.
- 24% led to unexpected additional care.
- 12% led to severe temporary harm.
- 6% led to permanent loss of function.
- 2% led to permanent harm.
- 2% led to a psychological impact.
An estimated fewer than 2% of all sentinel events 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.