Sentinel Event Data General Information 1995 2013
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 - 2
Adverse Event Reporting States WASHINGTON MONTANA NORTH DAKOTA MINNESOTA MICHIGAN VERMONT MAINE OREGON CALIFORNIA NEVADA IDAHO UTAH WYOMING COLORADO COLORADO SOUTH DAKOTA NEBRASKA KANSAS IOWA WISCONSIN MISSOURI INDIANA ILLINOIS OHIO NEW YORK PENNSYLVANIA WEST VIRGINIA VIRGINIA KENTUCKY RHODE ISLAND CONNECTICUT NEW JERSEY DELAWARE MARYLAND NEW HAMPSHIRE MASSACHUSETTS District of Columbia ARIZONA NEW MEXICO OKLAHOMA ARKANSAS TENNESSEE NORTH CAROLINA SOUTH CAROLINA PUERTO RICO HAWAII ALASKA TEXAS LOUISIANA MISSISSIPPI GEORGIA ALABAMA 26 States + D.C. The r reporting of events to The Joint Commission is a voluntary process, and represents only a small proportion of actual events. Therefore, this information should not be viewed as reflecting an epidemiologic data set and no conclusions should be drawn about the actual relative FLORIDA Office of Quality Monitoring - 3
Sources of Reported Reviewable Sentinel Events 2004 through 2013 www.jointcommission.org/self_report_form/ www.jointcommission.org/report_a_complaint.aspx Self Reported Media Other 1400 Number of Events Reviewed by TJC 1200 1000 800 600 400 200 0 2004 2005 2006 2007 2008 Date 2009 represents only a small proportion of actual events. Therefore, these data are not an 2010 2013 2012 2011 Office of Quality Monitoring - 4
Settings of Sentinel Events Reviewed by The Joint Commission 2004 through 2013 0 1000 2000 3000 4000 5000 6000 Hospital Psychiatric hospital Ambulatory care Psych unit in general hospital Emergency department Behavioral health facility Home care Long term care facility Other*** Office-based surgery 312 402 287 145 89 98 60 836 453 represents only a small proportion of actual events. Therefore, these data are not an 5199 ***Other includes: Disease specific care, Diagnostic imaging, Hospice care Office of Quality Monitoring - 5
Total Reported Reviewable Sentinel Events by Year 1995 through 2013 1400 Number of Reviewable Events Reported 1200 1000 800 600 400 200 0 1 1995 46 1996 122 1997 284 1998 401 1999 449 2000 429 2001 460 2002 545 550 607 2003 2004 2005 691 2006 represents only a small proportion of actual events. Therefore, these data are not an 790 2007 1243 927 938 920 901 887 2013 2012 2011 2010 2009 2008 Office of Quality Monitoring - 6
Most Frequently Reviewed Sentinel Event Categories by Year 2011 2012 2013 Unintended Retention of a Foreign Body Wrong-patient, wrong-site, wrong-procedure Delay In Treatment Unintended Retention of a Foreign Body Wrong-patient, wrong-site, wrong-procedure Delay In Treatment *Other includes: Unexpected Additional Care/Extended Care, and Psychological Impact represents only a small proportion of actual events. Therefore these data are not an Delay In Treatment Wrong-patient, wrong-site, wrong-procedure Unintended Retention of a Foreign Body Op/Post-op Complication Suicide Suicide Suicide Op/Post-op Complication Fall Fall Fall Other Unanticipated Event* Other Unanticipated Event* Other Unanticipated Event* Op/Post-op Complication Criminal Event Criminal Event Criminal Event Medication Error Medication Error Medication Error Medical Equipment-Related Perinatal Death/Injury Perinatal Death/Injury Office of Quality Monitoring - 7
RCA Review Methods Selected by Accredited Health Care Organizations 2004 through 2013 Alternative 1 RCA brought to The Joint Commission 18.6% Alternative 2 RCA documents reviewed on-site at the health care organization 2.1% 2.3% 0.7% Alternative 3 RCA reviewed by interviews on-site at the health care RCA submitted to The Joint Commission electronically 76.3% represents only a small proportion of actual events. Therefore, these data are not an Alternative 4 Focused Survey http://www.jointcommission.org/se_alternatives/ Office of Quality Monitoring - 8