The Sentinel Event Data Annual Report for 2023 is now available on The Joint Commission website, including a figure showing the trend of reported sentinel events by source from 2005-2023. From Jan. 1-Dec. 31, 2023, The Joint Commission reviewed 1,411 sentinel events. The most prevalent event types identified in 2023 include the following:
- Falls (48%)
- Wrong surgery (8%)
- Unintended retention of foreign object (8%)
- Assault/rape/sexual assault/homicide (8%)
- Delay in treatment (6%)
- Suicide (5%)
These event types comprised 83% of all reported sentinel events in 2023. The majority of these events – 96% (1,358) – were voluntarily self-reported to The Joint Commission by an accredited or certified entity. The remaining 53 sentinel events were reported either by anonymous sources, patients (or their families), or employees (current or former) of the organization.
Reporting sentinel events to The Joint Commission is a voluntary process, and, as such, epidemiological inferences are not reliable. No conclusions should be drawn about the actual relative frequency of events or trends in events over time.
The Joint Commission’s Sentinel Event Database includes de-identified data collected and analyzed from the review of sentinel events and subsequent comprehensive systematic analyses, such as root cause analyses, voluntarily submitted by health care organizations to The Joint Commission’s Office of Quality and Patient Safety (OQPS).
Upon receiving notice of a sentinel event, patient safety specialists within OQPS help the organization conduct a credible and thorough analysis to identify causative factors and implement relevant system solutions to prevent harm to patients. By partnering with OQPS, the organization receives an independent review of the event, insights from reviews of similar events, and suggestions for improvement strategies that have been successfully employed in other health care organizations.
In late April, The Joint Commission launched a fully redesigned E-dition, the Web-based tool that provides healthcare organizations access to all accreditation, certification, and verification requirements, including survey process content. The redesign is in response to user feedback.
The redesign improves navigation and usability, as well as modernizing the look and feel of the tool. Although E-dition will look different, users will still have access to all its current features. Users can still adjust their service profile to tailor their experience and, as applicable, have access to an interactive crosswalk showing how Joint Commission elements of performance (EPs) relate to U.S. Centers for Medicare & Medicaid Services (CMS) requirements.
Current E-dition users can access a recording of E-dition Modernization Training – a 30-minute presentation of the new features and functions – on the Joint Commission Resources website.