By Greg Freeman
EXECUTIVE SUMMARY
The Joint Commission reported an increase in sentinel events. Falls, which were the most common event, increased significantly in 2022.
- Communication failures were cited as a main cause of sentinel events.
- The increases may be tied to pandemic pressures on healthcare workers.
- Documentation burdens can negatively affect patient safety.
The Joint Commission’s (TJC’s) latest report on sentinel events shows a 19% increase from 2021 to 2022. Falls, which were the most common sentinel event, increased almost 27%.1
TJC cited failures in communication, teamwork, and following policies as the main cause for the reported events. Of the 1,441 events reported in 2022, 90% were reported voluntarily by the healthcare facility. The rest were reported by employees, patients, and family members.
Twenty percent of the reported events were associated with a patient death, and 44% with severe temporary harm. Thirteen percent were associated with unexpected additional care or an extended length of stay. Falls comprised 42% of the total sentinel events, with 5% causing death and 70% causing severe harm.
In a statement released with the report, Haytham Kaafarani, MD, MPH, FACS, chief patient safety officer and medical director for TJC, said the increase in reported events most likely was tied to the heavier demands and stress on healthcare workers during the pandemic.2
Several factors may be driving the increase in sentinel event reports, says Bette McNee, RN, NHA, assistant vice president at insurance broker Graham Company in Philadelphia. Staffing shortages and the pressures of the pandemic combined to threaten patient safety, she says, but the burden of clinical documentation also plays a role.
“Even prior to the pandemic, we had created a burden of clinical documentation. I think that plays into this issue. Folks are there to work, but it becomes like a culture of just compliance, checking the box,” McNee says. “You’ve got a shortage of workers, and then this culture of compliance, and this burden of clinical documentation really adds to all of the clinician burnout that we’re seeing.”
Although documentation is important in many ways, clinicians can believe it is prioritized over patient care, McNee notes. When that happens, clinicians can risk burnout and disengagement from patients, which leads to more sentinel events. The compliance burden can have the opposite effect of what it is intended to do.
“Sometimes, what is prioritized are those things that are checked. We are recommending in this post-pandemic culture that people do need to look at opportunities to reduce documentation,” McNee says. “Is there a technology that can capture services that don’t require the clinician to go in and have this belt-and-suspenders approach where they’re documenting twice? We need to find ways to keep documentation brief but thorough enough to record the services that are delivered.”
REFERENCES
- The Joint Commission. Sentinel Event Data 2022 Annual Review. April 4, 2023. https://www.jointcommission.or...
- The Joint Commission. The Joint Commission releases sentinel event data on serious adverse events at U.S. healthcare organizations. April 4, 2023. https://www.jointcommission.or...
SOURCE
- Bette McNee, RN, NHA, Assistant Vice President, Graham Company, Philadelphia. Email: [email protected].
The Joint Commission’s latest report on sentinel events shows a 19% increase from 2021 to 2022. Falls, which were the most common sentinel event, increased almost 27%.
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