Suicides, med errors top sentinel events list
There have been 655 sentinel events investigated since 1995, according to the latest information released by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Patient suicides and medication errors account for the most common types of sentinel events.
There were 127 patient suicides, making up 19.4% of all sentinel events. The next largest category was medication errors, with 89 cases making up 13.6% of the total. These were the other categories:
• operative or postoperative complications — 70 cases, 10.7%;
• wrong-site surgery — 50 cases, 7.6%;
• delay in treatment — 31 cases, 4.7%;
• patient death or injury in restraints — 30 cases, 4.6%;
• patient falls — 28 cases, 4.3%;
• assault/rape/homicide — 26 cases, 4%;
• patient elopement — 23 cases, 3.5%;
• transfusion error — 18 cases, 2.7%;
• infant abduction/wrong family — 17 cases, 2.6%;
• fire — 15 cases, 2.3%;
• medical equipment-related —- 13 cases, 2%;
• perinatal death/loss of function — 12 cases, 1.8%;
• maternal death — 10 cases, 1.5%;
• ventilator death/injury — 11 cases, 1.7%;
• utility system failure — 9 cases, 1.4%;
• death associated with transfer — 6 cases, 0.9%;
• infection-related death — 6 cases, 0.9%;
• dialysis-related event — 3 cases, 0.5%;
• inpatient drug overdose — 3 cases, 0.5%;
• various other types — 58 cases, 8.9%.
The statistics show that 417 cases, 63.7% of the total, occurred in a general hospital setting, while 108, or 16.5%, occurred in a psychiatric hospital. Another 46, or 7%, took place on a psych unit in a general hospital. Long-term care facilities made up 27 cases, or 4.1%. These were the other settings:
• emergency department — 19 cases, 2.9%;
• behavioral health facility — 17 cases, 2.6%;
• home care — 11 cases, 1.7%;
• ambulatory care — seven cases, 1.1%;
• clinical laboratory — two cases, 0.3%;
• health care network — one case, 0.2%.
Most of the sentinel events, 393, or 60%, were self-reported by the providers. Another 140, 21.4%, were discovered in media reports, and 77, 11.8%, were identified during a Joint Commission survey. Patients and families reported 26 cases, 4%, and reports from other professional groups accounted for 14 cases, or 2.1%. Employees of the health care provider reported five cases, or 0.8%.
Seventy-eight percent of the sentinel events, 562 cases, resulted in the patient’s death. Another 45 cases, 6%, resulted in loss of function. The total number of patients affected by the sentinel events was 722.
The number of sentinel events investigated by the Joint Commission has risen steadily since 1995, partly because of the way it has defined the events and increased attention to them. There were 23 sentinel events investigated in 1995, 33 in 1996, 138 in 1997, 180 in 1998, and 280 in 1999.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content