Joint Commission: Surgical errors top latest list of sentinel events
Wrong-patient, wrong-site, or wrong-procedure errors top the list of sentinel event statistics reported to The Joint Commission through the second quarter of 2015. The accreditor reviewed 474 sentinel events through the first half of the year, with 58 wrong patient/site/procedure errors reported. Next on the list were unintended retention of foreign body (50), suicide (48), fall (39), and delay in treatment (37).
Of the 9,119 incidents reviewed by The Joint Commission since 2004, 5,383 (57.4%) resulted in patient death, 9% ended in permanent loss of function, and 29.6% led to unexpected additional care and/or psychological impact. The leading root cause for sentinel events is human factors (e.g., staff supervision issues) with 464, followed by leadership (382), and communication (with patients or administration) with 343.