Cognitive failure was the root cause of most sentinel events in 2014, according to new statistics from The Joint Commission (TJC).
The Joint Commission reviewed 764 sentinel events during 2014. The most frequently reported sentinel event was unintended retention of a foreign object, accounting for 112 events. The next most frequent was falls, followed by suicide; delay in treatment; other unanticipated events; wrong patient, wrong site, or wrong procedure; operative or postoperative complication; criminal event; perinatal death or injury; and medication error.
Data from the 8,645 incidents reviewed from 2004 through 2014 show that 8,876 patients have been affected by these events, with 5,177 (58.3%) resulting in the patient’s death, 831 (9.4%) resulting in loss of function, and 2,868 (32.3%) resulting in unexpected additional care and/or psychological impact.
All sentinel events are subject to review by the TJC.
The report is available at http://tinyurl.com/leojogo.
