Wrong-site, wrong-patient, and wrong-procedure surgery continues to be the sentinel event most frequently reported to the Joint Commission, with 1,196 such events reported through September 30, 2015, according to recently updated statistics provided by the accreditor. The next most frequently reported events include unintended retention of a foreign object (1,072), delays in treatment (1,035), suicide (932), and operative or postoperative complications (904). The most frequently reported events in 2015 mirror the overall data since 2004 presented above, with one exception: falls, with 66 reported events in 2015, was the fourth most frequently reported event during the calendar year despite being sixth most frequently reported overall. More than half (57%) of the reported sentinel events resulted in patient death, followed by unexpected additional care (26.5%) and permanent loss of function (8.9%).
HRC Recommends: Organizations should actively maintain multidisciplinary committees to analyze such events when they occur in the facility and to determine causal and contributing factors with the goal of applying learning to lessen the risk of recurrence. Myriad strategies exist to help improve patient safety; designated committees should identify those with merit for the organization, as well as other resources, and determine ways to strengthen care delivery systems. Efforts should be tracked and trended to monitor success and determine where further improvement is needed.