The Joint Commission Releases 2023 Sentinel Event Data Report


The Joint Commission Releases 2023 Sentinel Event Data Report

The Joint Commission published its Sentinel Event Data 2023 Annual Review last week, according to a report on Joint Commission Online. The annual review includes a figure showing the trend of reported sentinel events by source from 2005 to 2023. From January 1 to December 31, 2023, The Joint Commission reviewed 1,411 sentinel events. The most prevalent event types identified in 2023 include the following:

  • Falls (48 percent)
  • Wrong surgery (8 percent)
  • Unintended retention of foreign object (8 percent)
  • Assault/rape/sexual assault/homicide (8 percent)
  • Delay in treatment (6 percent)
  • Suicide (5 percent)

These event types comprised 83 percent of all reported sentinel events in 2023, according to the review. The majority of these events96 percent (1,358)were voluntarily self-reported to The Joint Commission by an accredited or certified entity. The remaining 53 sentinel events were reported either by anonymous sources, patients (or their families) or employees (current or former) of the organization.

Reporting sentinel events to The Joint Commission is a voluntary process, and, as such, epidemiological inferences are not reliable, the report states. No conclusions should be drawn about the actual relative frequency of events or trends in events over time.

The Joint Commission’s Sentinel Event Database includes de-identified data collected and analyzed from the review of sentinel events and subsequent comprehensive systematic analyses, such as root cause analyses, voluntarily submitted by healthcare organizations to The Joint Commission’s Office of Quality and Patient Safety (OQPS), according to the report.

Upon receiving notice of a sentinel event, patient safety specialists within OQPS help the organization conduct a credible and thorough analysis to identify causative factors and implement relevant system solutions to prevent harm to patients, according to the report. By partnering with OQPS, the organization receives an independent review of the event, insights from reviews of similar events and suggestions for improvement strategies that have been successfully employed in other healthcare organizations.

Access the report.