The Joint Commission releases annual Sentinel Event Data Report

Editor's Note

According to the annual Sentinel Event Data Report, The Joint Commission received 1,411 reports of sentinel events—an event not related to the natural course of an illness or condition that causes severe harm, permanent harm or death—in 2023. Of that total, 96% of events were voluntary self-reported by an accredited or certified entity, and 88% occurred in a hospital.

More than 8 in 10 sentinel events fit within one of the following categories:

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

The most severe harm, patient death, was associated with 18% of reported sentinel events. Another 8% of events resulted in permanent harm or loss of function, while 57% caused severe temporary harm and 12% led to the need for unexpected, additional treatment. Of events resulting in patient death, delay in treatment was the second most harmful event category following patient suicides with 69% of delays resulting in death.

The organization emphasizes that reporting is voluntary, so epidemiological inferences are not reliable and no conclusions should be drawn about the actual relative frequency of events or trends over time.