Wrong patient/site/procedures lead all sentinel events in first half of 2013

Sixty wrong-patient/wrong-site/wrong-procedure sentinel events were reported during the first half of 2013, according to the October edition of The Joint Commission Perspectives. Other sentinel events near the top of the list were unintended retention of a foreign object and delay in treatment resulting in death or permanent loss of function, each of which was reported 56 times; and falls resulting in death or permanent loss of function, with a reported 48 instances, The Joint Commission stated.

The accreditation organization reviewed 446 sentinel events during the first half of the year. Fewer than 2% of all sentinel events are reported to The Joint Commission and only about two-thirds of these are voluntarily reported, according to the article. The report listed human factors (such as fatigue or distraction) as root causes of 314 of these events; communication issues among staff, across disciplines, or with patients were root causes in 292 cases; and leadership—regarding, for example, lack of performance improvement infrastructure or community relations—were root causes in 276 of these events.

Source: The Joint Commission