7391 1995 1 1996 29 1997 119 1998 272 1999 421 2000 441 2001 398 2002 444 2003 416 1995 to 2003 Total 2541 Sources of Reviewable Sentinel Events 2004 through 2010 Total Incidents Self- Reported Non- Self Reported % of Self Reported Sentinel Event Settings 2004 through 2010 # % 2004 418 267 151 63.9% Hospital 3097 63.9% 2005 592 367 225 62.0% Psychiatric hospital 555 11.4% 2006 511 357 154 69.9% Ambulatory care 189 3.9% 2007 740 448 292 60.5% Psych unit in general hospital 270 5.6% 2008 819 509 310 62.1% Emergency department 328 6.8% 2009 968 624 344 64.5% Behavioral health facility 187 3.9% 2010 802 572 230 71.3% Home care 80 1.6% 2004 through 2010 Total 4850 3144 1706 64.8% Long term care facility 63 1.3% Other** 60 1.2% Type of Sentinel Event 2004 through 2010 Total 2008 2009 2010 Office-based surgery 21 0.4% Abduction 22 3 1 1 Total 4850 Anesthesia-Related Event 71 6 15 6 Criminal Event 188 42 34 28 Delay In Treatment 545 103 123 95 Dialysis-Related Event 6 0 2 2 Sentinel Event Outcome 2004 through 2010 # % Elopement 61 11 8 14 Patient death 3032 61.8% Fall 366 63 81 56 Loss of Function 459 9.4% Fire 68 12 15 8 Other*** 1418 28.9% Infant Discharge to Wrong Family 2 1 0 1 Total patients impacted***** 4909 100.0% Infection-Related Event 121 12 28 14 Inpatient Drug Overdose 42 3 7 8 Maternal Death 81 5 13 16 Med Equipment-Related 137 26 24 25 Medication Error 291 50 43 44 Op/Post-op Complication 504 71 94 86 Other Unanticipated Event**** 296 41 52 38 Perinatal Death/Injury 167 32 31 31 Radiation Overdose* 19 3 5 8 Restraint Related Event 95 13 11 5 Self-Inflicted Injury 35 6 6 7 Severe Neonatal Hyperbilirubinemia* 3 0 0 2 Suicide 469 103 87 67 Transfer-Related Event 13 3 2 3 Transfusion Error 78 19 12 5 Unintended Retention of a Foreign Body* 470 70 119 133 Utility System Failure 4 2 0 0 Ventilator Death 30 4 6 6 Wrong–patient, wrong-site, wrong-procedure 666 116 149 93 Total Incidents Reviewed 4850 820 968 802 SE Statistics as of: December 31, 2010 Summary Data of Sentinel Events Reviewed by The Joint Commission Total Incidents Reviewed 1995 through 2003 Total number of Sentinel Events reviewed by The Joint Commission 1995 through 2010 © Copyright, The Joint Commission The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time. *Unintended retention of a foreign object , Severe Neonatal Hyperbilirubinemia & Radiation Overdose were added to the definition of reviewable events in 2005. This data represents events reviewed since that date, not 1995-2010. **Other includes: Disease Specific Care, Diagnostic Imaging, Hospice Care ***Other includes: Unexpected Additional Care/Extended Care, and Psychological Impact ****Oth er include: Asphyxiat ion, Burn, Choked on food, Drowned, Found unresponsive *****Mu ltiple patients may be impacted by a single 0 200 400 600 800 1000 1200 2004 2005 2006 2007 2008 2009 2010 N u m b e r o f E v e n t s R e v i e w e d b y T J C Date Self Reported Media Other
