9535

SE Statistics as of: 12/31/2012
Summary Data of Sentinel Events Reviewed by The Joint Commission
Data Limitations: 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.
Total number of Sentinel Events reviewed by The Joint Commission 1995 through 2012
9535
Total Incidents Reviewed 1995 through 2003
1995
1996
1997
1998
1999
2000
2001
2002
2003
1995 to 2003 Total
1
29
119
272
421
441
398
444
416
2541
Number of Events Reviewed by TJC
Self Reported
Media
Other
1400
1200
1000
800
600
400
200
0
2012
2011
2010
2009
2008
2007
2006
2005
2004
Date
Sources of Reviewable Sentinel Events 2004
Non-self reported Self Reported
through 2012
2004
2005
2006
2007
2008
2009
2010
2011
2012
2004 through 2012 Total
Type of Sentinel Event
Anesthesia-Related Event
Criminal Event
Delay In Treatment
Dialysis-Related Event
Elopement
Fall
Fire
Infant Abduction
Infant Discharge to Wrong Family
Infection-Related Event
Inpatient Drug Overdose
Maternal Death
Med Equipment-Related
Medication Error
Op/Post-op Complication
Other Unanticipated Event****
Perinatal Death/Injury
Radiation Overdose*
Restraint Related Event
Self-Inflicted Injury
Severe Neonatal Hyperbilirubinemia*
Suicide
Transfer-Related Event
Transfusion Error
Unintended Retention of a Foreign Body*
Utility System Failure
Ventilator Death
Wrong–patient, wrong-site, wrong-procedure
Total Incidents Reviewed
151
225
154
292
310
344
230
378
253
2337
2004 - 2012 Total
94
267
367
357
448
509
624
572
865
648
4657
Total
%Self Reported
418
592
511
740
819
968
802
1243
901
6994
2011
2010
63.9%
62.0%
69.9%
60.5%
62.1%
64.5%
71.3%
69.6%
71.9%
66.6%
Sentinel Event Settings 2004
through 2012
Hospital
Psychiatric hospital
Ambulatory care
Psych unit in general hospital
Emergency department
Behavioral health facility
Home care
Long term care facility
Other***
Office-based surgery
#
4545
784
289
361
428
253
129
84
72
46
%
65.0%
11.2%
4.1%
5.2%
6.1%
3.6%
1.8%
1.2%
1.0%
0.7%
2012
6
16
7
280
790
28
95
49
138
43
107
9
79
538
98
26
3
153
83
107
193
378
719
425
239
30
117
55
6
685
24
114
773
7
41
928
6994
2
14
56
8
1
1
14
8
16
25
44
86
38
31
8
5
7
2
67
3
5
133
0
6
93
802
1
8
96
15
1
0
20
19
18
39
45
133
71
36
8
15
6
1
131
7
20
188
2
8
152
1243
2
10
76
15
3
1
12
22
8
17
42
83
59
36
3
7
14
2
85
3
16
115
1
3
109
901
Sentinel Event Outcome 2004
through 2012
Patient death
Loss of Function
Other***
Total patients impacted*****
#
%
4230
59.9%
654
2177
7061
9.3%
30.8%
100.0%
*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
****Other include: Asphyxiation, Burn, Choked on food,
Drowned, Found unresponsive
*****Multiple patients may be impacted by a single event.
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