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Founded in 1951, The Joint Commission seeks to continuously improve healthcare for the public, in collaboration with other stakeholders, by evaluating healthcare organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

The Joint Commission accredits and certifies more than 22,000 healthcare organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in healthcare.

In 1996, The Joint Commission created a Sentinel Event Policy to help healthcare organizations that experience serious adverse events improve safety. The Joint Commission’s Office of Quality and Patient Safety assists healthcare organizations in conducting comprehensive systemic analyses to learn from these sentinel events. Since that time, The Joint Commission has maintained an associated Sentinel Event Database with de-identified and aggregate data

According to the latest 2022 Annual Report released on April 4, between January 1 and December 31, 2022, the Joint Commission received 1,441 reports of sentinel events; the majority – 90% (1,299) – were voluntarily self-reported to The Joint Commission by an accredited or certified entity. The number of reported sentinel events increased by 19% compared to 2021. The majority of reported sentinel events occurred in the hospital setting (88%).

As in previous years, patient falls was the most commonly reported sentinel event (42%) in 2022. Falls have been the leading sentinel event type reviewed since 2019. There were 611 sentinel events classified as patient falls in 2022 – a 27% increase from 2021. Of these patient falls, 5% resulted in death and 70% in severe harm to the patient. Leading injuries included head injury/bleed and hip/leg fracture.

Reported contributors to falls included policies not being followed (e.g., fall risk assessment), inadequate staff-to-staff communication during handoffs or transitions of care, and lack of shared understanding or mental model regarding plan of care.

The remaining leading categories were delay in treatment (6%), unintended retention of foreign object (6%), wrong surgery (6%) and suicide (5%).

Reported contributors to delays in treatment included no or inadequate staff-to- staff communication of critical information, staff lacking competency to recognize abnormal clinical signs, and policies not being followed (e.g., observation rounds).

Sentinel events classified as unintended retention of a foreign object continue to decline with 88 reported in 2022. Outcomes associated with unintended retention of a foreign object included severe harm to the patient (40%), unexpected additional care or extended stay (35%) or other/no harm (16%)

Wrong surgeries include surgeries or invasive procedures that are performed at the wrong site or on the wrong patient, or that are the wrong (unintended) procedure for a patient regardless of the type of procedure or the magnitude of outcome. There were 85 sentinel events classified as wrong surgeries in 2022. Of these, a majority were surgeries or invasive procedures performed at the wrong site (65%).

There were 73 sentinel events classified as suicide in 2022. Of these, 55% occurred off site within 72 hours of discharge from an accredited healthcare organization, 40% occurred in an inpatient setting, and 4% while in the emergency department.

Death by ligature was the leading means by which a patient died by suicide (33%) followed by gunshot (14%) and jumping from height (11%). Leading factors associated with suicide included policies not being followed or adhered to, no or inadequate staff-to-staff communication of critical information, and inadequate or inappropriate precautions for high-risk or impaired patients.

When analyzing the root cause of sentinel events, communication breakdowns (e.g., not establishing a shared understanding or mental model across care team members, or no or inadequate staff-to-staff communication of critical information) continue to be the leading factor contributing to sentinel events.

Of reviewed sentinel events in 2022, 20% resulted in patient death, 6% in permanent harm or loss of function, 44% in severe temporary harm, and 13% in unexpected additional care/extended stay. Sentinel events resulting in death were most commonly associated with patient suicide (24%), delays in treatment (21%), and patient falls (11%). Events resulting in severe temporary harm were most commonly associated with patient falls (62%).