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Falls top Joint Commission's annual adverse event report again

por Gus Iversen, Editor in Chief | April 07, 2023
Risk Management
The Joint Commission has released its Sentinel Event Data 2022 Annual Review on serious adverse events from Jan. 1 through Dec. 31, 2022, compiling data on patient safety events that resulted in death, permanent harm or severe temporary harm.

All told, the JC reviewed 1,441 sentinel events in 2022, with the most prevalent being:

  • Falls (42%)
  • Delay in treatment (6%)
  • Unintended retention of foreign object (6%)
  • Wrong surgery (6%)
  • Suicide (5%)

Consistent with previous years, patient falls were the leading event type reviewed, with 40% of falls taking place while ambulating, 23% involving a fall from bed, and 10% involving "toileting".

Failures in communications, teamwork and consistently following polices were the leading causes for reported sentinel events. Most reported sentinel events occurred in a hospital (88%). Of all the sentinel events, 20% were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional care/extended stay.

“COVID-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” noted Dr. Haytham Kaafarani, chief patient safety officer and medical director, The Joint Commission. “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. Our goal is to help prevent these types of adverse events from occurring again.”

The majority of sentinel events (90%) were voluntarily self-reported to The Joint Commission by an accredited or certified healthcare organization. The remaining sentinel events were reported either by patients or their families, or employees of a healthcare organization. There were 1,441 sentinel events reported in 2022, a 19% increase compared to 2021 and a 78% increase from 2020.

The full report can be read here.

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