The Joint Commission implemented a sentinel event policy in 1996 to help hospitals improve patient safety and learn from adverse events, including unexpected deaths and serious physiological or psychological harm to patients.
The organization defines a sentinel event as a patient safety event that results in any of the following outcomes: death, permanent harm, severe temporary harm or intervention required to sustain life. The Joint Commission requires hospitals to conduct a root-cause analysis after a sentinel event occurs.
The nonprofit organization also considers the National Quality Forum's "never events" to be sentinel events, according to the Agency for Healthcare Research and Quality.
NQF classifies the following circumstances as never events: surgical events, product or device events, patient protection events, care management events, environmental events, radiologic events and criminal events.
Frequency of never events
Although most never events are rare, these safety incidents can have significant effects on patients and hospitals. Here are three statistics on the frequency of never events, compiled by the Agency for Healthcare Research and Quality:
1. More than 4,000 surgical never events occur each year in the U.S., according to a 2013 study.
2. The average hospital may experience a wrong-site surgery case once every 5 to 10 years, according to a 2006 study.
3. The majority — 71 percent — of never events reported to The Joint Commission between 1995 and 2015 were fatal.
Most common never events
In March 2018, The Joint Commission updated its sentinel event statistics for 2017. The organization reviewed 805 reports of sentinel events reported during the 2016-17 calendar year.
Here are the 10 most frequently reported sentinel events for 2017, according to The Joint Commission:
1. Unintended retention of a foreign body — 116 reported
2. Fall — 114
3. Wrong-patient, wrong-site, wrong-procedure — 95
4. Suicide — 89
5. Delay in treatment — 66
6. Other unanticipated event, such as asphyxiation, burn, choking on food, drowning or being found unresponsive — 60
7. Criminal event — 37
8. Medication error — 32
9. Operative/postoperative complication — 19
10. Self-inflicted injury — 18
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