Tag Archives: Wrong-Side Surgery

Joint Commission Updates Sentinel Event Statistics Through Q3 2015, URFOs Top List

The Joint Commission has updated its Sentinel Event statistics through Q3 2015, and published four related presentations.

Since The Joint Commission implemented the Sentinel Event database in January 1995 the organization has reviewed a total of 11,917 Sentinel Events and issued 55 Sentinel Event Alerts, the most recent being Sentinel Event Alert #55: Preventing Falls and Fall-Related Injuries in Health Care Facilities on September 28, 2015.

In 2011, The Joint Commission began presenting data for specific analytics dating back to 2004 only, including reporting source, Sentinel Event setting, and Sentinel Event outcome. Data for these analytics from 1995 to 2003 is not provided.

According to the latest statistics, since 2004 The Joint Commission has reviewed 9,376 Sentinel Events, determined 9,594 patients were impacted by these events, and identified 5,469 (57%) of the events resulted in patient death and 857 (8.9%) resulted in permanent loss of function. Since 2004, the majority of reviewed Sentinel Events (6,248, 66.7%) occurred in the hospital setting.

Links to the individual Sentinel Event presentations are included below.

Sentinel Event-related data demonstrates the need of the Joint Commission and accredited health care organizations to continue to address serious adverse events. The data also supports the importance of establishing National Patient Safety Goals (NPSGs) and focusing energies on addressing serious errors within health care organizations. By identifying causes, trends, settings and outcomes of Sentinel Events, The Joint Commission can provide critical information in the prevention of Sentinel Events to accredited health care organizations and to the public.

The Joint Commission cautions that the reporting of most Sentinel Events is voluntary and represents only a small proportion of actual events. Therefore, the data is epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Joint Commission Updates Sentinel Event Statistics Through Q1 2012

The Joint Commission has updated its Sentinel Event statistics through March 31, 2012 and published four related presentations, including general information on Sentinel Event data, root causes by event type, event type by year, and a summary of Sentinel Event data.

Since the Joint Commission implemented its Sentinel Event database in January 1995, the organization, through Q1 2012, has reviewed a total of 8,859 Sentinel Events, and issued 48 Sentinel Event Alerts. The latest Sentinel Event Alert, focusing on health care worker fatigue and its potential effect on patient safety, was issued in December 2011.

The Joint Commission has determined that Sentinel Events reviewed since 2004 have resulted in 3,859 patient deaths and impacted 6,383 patients, including unanticipated additional care, extended care, and psychological Impact.

Sentinel Events are divided into 27 specific categories, with a 28th category that includes the remaining ‘other unanticipated event[s].’ In Q1 2012, The Joint Commission reviewed 225 Sentinel Events, with the most reviewed event being ‘Unintended Retention of a Foreign Body’ (42), followed by ‘Delay in Treatment’ (33), then ‘Wrong-Site, Wrong-Patient, Wrong-Procedure’ events(27).

In 2011, ‘Perinatal Death or Injury,’ the ninth most reviewed event in 2010, and the tenth most reviewed event in 2009, was removed from the top ten most reviewed Sentinel Event list, and replaced at number ten by ‘Medical Equipment-Related’ events. ‘Medical Equipment-Related’ events had been the eleventh most reviewed Sentinel Event in 2010. In Q1 2012, there were six ‘Perinatal Death or Injury’ events and two ‘Medical Equipment-Related’ events reviewed.

Sentinel Event Data Summary (as of March 31, 2012)
[Download]

“This sentinel event-related data, reported to The Joint Commission from our accredited organizations, demonstrates the need of the Joint Commission and accredited health care organizations to continue to address these serious adverse events. This data also supports the importance of establishing National Patient Safety Goals and focusing our energies on addressing serious errors within health care organizations. By identifying causes, trends, settings and outcomes of sentinel events, The Joint Commission can provide critical information in the prevention of sentinel events to accredited health care organizations and the public.”

[The Sentinel Event Data Summary] Includes:

  • Type of Sentinel Event
  • Settings of Sentinel Events
  • Sources for SE Identification
  • Sentinel Event Outcomes
  • Self-reported Sentinel Events by Year
  • Method for Review of HCO Response to Sentinel Event

Sentinel Event Data – General Information (1995 – Q1 2012)
[Download]

“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.”

Sentinel Event Data – Event Type By Year (1995 – Q1 2012)
[Download]

Sentinel Event Data – Root Causes By Event Type (2004 – Q1 2012)
[Download]

NQF Endorses 14 New Quality Measures Focusing on Care Complications; Measures Include Medication Safety, Surgical Safety, and Care Coordination

On Tuesday, June 19, 2012, The National Quality Forum (NQF) endorsed 14 new patient safety quality measures focused on reducing care complications such as medication errors, venous thromboembolism, care coordination, and surgical safety issues, including wrong-site surgery and patient burns, according to an NQF press release.

NQF reviewed 27 proposed measures and ultimately endorsed 14 of them for at least three years, with ongoing evaluation and updating to follow. The organization left an additional three patient safety quality measures under consideration.

“Preventable errors in healthcare are costing Americans in a number of ways, whether in premiums, lost work time and wages or undue stress and anxiety for patients and families,” Detroit’s Henry Ford Health System Senior Vice President and Chief Quality Officer William A. Conway said in a statement. “This measure set will ensure the healthcare community has the right measurement tools to help alleviate these burdens and provide patients with high-quality care.”

To date in 2012, NQF has endorsed 180 new quality measures.

The 14 newly endorsed patient safety quality measures are as follows:

  • 0022: Use of High Risk Medications in the Elderly (NCQA)
  • 0372: Intensive Care Unit Venous Thromboembolism Prophylaxis (Joint Commission)
  • 0373: Venous Thromboembolism Patients with Anticoagulant Overlap Therapy (Joint Commission)
  • 0450: Postoperative Pulmonary Embolism or Deep Vein Thrombosis Rate (PSI 12) (AHRQ)
  • 0267: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant (Ambulatory Surgical Center Quality Collaboration)
  • 0344: Accidental Puncture or Laceration Rate (PDI 1) (AHRQ)
  • 0345: Accidental Puncture or Laceration Rate (PSI 15) (AHRQ)
  • 0362: Foreign Body left after procedure (PDI 3) (AHRQ)
  • 0363: Foreign Body Left During Procedure (PSI 5) (AHRQ)
  • 0263: Patient Burn (Ambulatory Surgical Center Quality Collaboration)
  • 0346: Iatrogenic Pneumothorax Rate (PSI 6) (AHRQ)
  • 0348: Iatrogenic Pneumothorax Rate (PDI 5) (AHRQ)
  • 0349: Transfusion Reaction (PSI 16) (AHRQ) (reserve status)
  • 0350: Transfusion Reaction (PDI 13) (AHRQ) (reserve status)

The June 19, 2012 NQF press release announcing the endorsement of the new complications-related patient safety measures is available here.

To learn more about additional quality measures NQF has endorsed in 2012, read NQF Endorses Over 160 New Quality Measures in Q1, Q2 2012, Retires 22 Measures right here on HNX Healthcare Update.