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Sentinel Event Data
Event Type by Year
1995-2012
Office of Quality Monitoring - 2
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Sentinel Event
A sentinel event is an unexpected occurrence involving
death or serious physical or psychological injury, or the
risk thereof. Serious injury specifically includes loss of
limb or function. The phrase “or risk thereof” includes any
process variation for which a recurrence would carry a
significant chance of a serious adverse outcome.
Such events are called “sentinel” because they signal the
need for immediate investigation and response.
The term “sentinel event” and “medical error” are not
synonymous; not all sentinel events occur because of an
error, and not all error result in sentinel events.
http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/
Office of Quality Monitoring - 3
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Reviewable Sentinel Events
The event has resulted in an unanticipated death or major permanent loss of function, not
related to the natural course of the patient’s illness or underlying condition.
OR
The event is one of the following and does not require an outcome of death or major
permanent loss of function:
Suicide of any patient receiving care, treatment and services in a staffed around-the-
clock care setting or within 72 hours of discharge.
Unanticipated death of a full-term infant
Abduction of any patient receiving care, treatment, and services
Discharge of an infant to the wrong family
Rape
Hemolytic transfusion reaction involving administration of blood or blood products having
major blood group incompatibilities
Surgical and nonsurgical invasive procedures on the wrong patient, wrong site, or wrong
procedure
Unintended retention of a foreign object in a patient after surgery or other procedure
Severe neonatal Hyperbilirubinemia (bilirubin >30 miligrams/deciliter)
Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or any delivery
of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose
.
http://www.jointcommission.org/Sentinel_Event_Policy_and_Procedures/
Office of Quality Monitoring - 4
© Copyright, The Joint Commission
Data Limitations
The reporting of most sentinel events to
The Joint Commission is voluntary and
represents only a small proportion of
actual events. 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.
Office of Quality Monitoring - 5
© Copyright, The Joint Commission
Abduction Events
Reviewed by The Joint Commission
(Of any individual receiving care, treatment or services)
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. 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.
0 0
3
4
4
9
2 2
1
2
4 4
7
3
1 1 1
3
0
5
10
15
20
25
30
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by TJC
Sentinel Event Alert
#9: "Infant Abductions"
April 1999
Office of Quality Monitoring - 6
© Copyright, The Joint Commission
Anesthesia-related Events
Reviewed by The Joint Commission
(Resulting in death or permanent loss of function)
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. 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.
0
1
0
4
6
8
3
4
6
10
12
8
14
6
15
6
16
7
0
5
10
15
20
25
30
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Sentinel Event Alert
#32: "Anesthesia Awareness"
October 2004
Office of Quality Monitoring - 7
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Criminal Events Assault/Rape/Homicide
Reviewed by The Joint Commission
(Rape defined as un-consented sexual contact. One or more of the following
must be present to determine reviewability: Any staff witnessed sexual contact;
or sufficient clinical evidence or admission by the perpetrator)
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. 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.
0
1
7
12
11
16
15
9
3
16
13
20
35
42
34
28
49
43
0
10
20
30
40
50
60
70
80
90
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Sentinel Event Alert
#45: "Preventing Violence in
Healthcare Settings" June
2010
Office of Quality Monitoring - 8
© Copyright, The Joint Commission
Delay in Treatment Events
Reviewed by The Joint Commission
(Resulting in death or permanent loss of function)
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. 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.
1
3
7
18
18
35
26
36
37
50
54
42
78
103
123
95
138
107
0
20
40
60
80
100
120
140
160
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Sentinel Event Alert
#26: "Delay in
Treatment"
June 2002
Office of Quality Monitoring - 9
© Copyright, The Joint Commission
Elopement-related Events
Reviewed by The Joint Commission
(Resulting in death or permanent loss of function)
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. 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.
0
1 1
7
12
4
7 7
8
7
11
5 5
11
8
14
4
10
0
5
10
15
20
25
30
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Office of Quality Monitoring - 10
© Copyright, The Joint Commission
Fall-related Events
Reviewed by The Joint Commission
(Resulting in death or permanent loss of function)
The reporting of most sentinel events to The Joint Commission is voluntary and
represents only a small proportion of actual events. 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.
0
2 2
13
23
25
21
17
18
31
47
35
53
63
81
56
96
76
0
20
40
60
80
100
120
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
Number of Events Reviewed by
TJC
Sentinel Event Alert
#14: "Fatal Falls-Lessons for
the Future" July 2000
[...]... 15 Sentinel Event Alert #18: "Kernicterus Threatens Health of Infants" April 2001 Sentinel Event Alert #31: "Revised Guidelines to Help Prevent Kernicterus" August 2004 10 Added to Sentinel Event Policy in 2005 5 1 0 2012 The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events Therefore, these data are not an epidemiologic data. .. relative frequency of events or trends in events over time 2011 0 2010 0 2009 2006 2005 2004 0 2008 0 2 2007 0 0 1 Office of Quality Monitoring - 12 © Copyright, The Joint Commission Number of Events Reviewed by TJC 30 Infection-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 28 Sentinel Event Alert #28: "Infection Control Related Sentinel Events" January... reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events 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 2007 2006 2005 2004 2001 2000 1999 1998 1996 1 0 1997 0 1995 0 14 2003 10 Sentinel Event Alert #22: "Preventing Needle... Commission 2 2000 1996 2 4 7 0 1998 0 1997 0 1995 0 3 3 4 6 2009 5 6 2008 7 1999 Number of Events Reviewed by TJC 30 Suicide Events Reviewed by The Joint Commission 140 Sentinel Event Alert #7: 120 "Inpatient Suicides: Recommendations for Prevention" 100 November 1998 80 Sentinel Event Alert #46: "A Follow-Up Report on Preventing Suicide" November 2010 71 85 67 53 55 49 40 87 63 58 60 103 Definition revised... actual events 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 Office of Quality Monitoring - 27 © Copyright, The Joint Commission Number of Events Reviewed by TJC 200 Ventilator-related Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 25 20 Sentinel. .. 15 2002 Number of Events Reviewed by TJC 30 Inpatient Drug Overdose Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) 25 22 19 20 15 10 6 4 8 3 2012 2011 2010 2009 The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events Therefore, these data are not an epidemiologic data set and no conclusions... relative frequency of events or trends in events over time 2008 2007 2006 2005 2002 2001 1997 2000 1996 3 4 7 0 1999 0 1998 0 1995 0 3 7 Office of Quality Monitoring - 14 © Copyright, The Joint Commission 5 4 2004 4 7 7 2003 Number of Events Reviewed by TJC 30 Maternal Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function) Sentinel Event Alert # 44: "Preventing Maternal... reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events 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 Office of Quality Monitoring - 17 © Copyright, The Joint Commission Number of Events Reviewed by TJC 90 Op/Post-op... of Events Reviewed by TJC 90 Perinatal Events Reviewed by The Joint Commission (Resulting in death or permanent loss of function full-term infant 2500g or > and absence of obvious congenital abnormality) 80 Sentinel Event Alert #30: "Preventing Infant Death & Injury in Delivery" July 2004 70 60 50 2012 31 2010 36 2011 31 2009 30 24 11 2003 14 19 2007 2006 2005 2004 The reporting of most sentinel events... actual events 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 Office of Quality Monitoring - 20 © Copyright, The Joint Commission 10 2002 1997 13 16 1 1999 2 1998 0 1996 10 12 2001 10 2000 17 20 0 36 32 2008 40 1995 Number of Events Reviewed by TJC 90 Radiation Overdose Events Reviewed by . Commission
Sentinel Event Data
Event Type by Year
1995-2012
Office of Quality Monitoring - 2
© Copyright, The Joint Commission
Sentinel Event
A sentinel. of Events Reviewed by
TJC
Sentinel Event Alert
#17: "Fires in the
Home Care Setting"
March 2001
Sentinel Event Alert
# 29: "Preventing
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Xem thêm: Sentinel Event Data Event Type by Year 1995-2012 pdf, Sentinel Event Data Event Type by Year 1995-2012 pdf, Criminal Events -- Assault/Rape/Homicide Reviewed by The Joint Commission (Rape defined as un-consented sexual contact. One or more of the following must be present to determine reviewability: Any staff witnessed sexual contact; or sufficient clini