Sentinel Events for First Half of 2020 Drop Slightly

By A.J. Plunkett

The number of sentinel events reviewed by The Joint Commission (TJC) in the first half of this pandemic-dominated year are well under the pace for last year. But that’s probably not unexpected given the lockdown of the nation’s hospitals as they focused on preparing for the 2019 coronavirus patient surge.

In announcing the statistics for the review period of January 1 through June 30 of this year, TJC noted that while the focus on COVID-19 patients presented significant and unique challenges for all healthcare organizations, “future studies will be required to fully quantify its true impact as a causative factor in sentinel events,” said Raji Thomas, DNP, MBA, CPHQ, CPPS, director of TJC’s Office of Quality and Patient Safety in the statement released online.

As in 2019, care management problems led the list of sentinel events. That same year, TJC grouped different categories together. The care management category, including falls, delays in treatment and medication management errors.

Next on the sentinel list was surgical or invasive procedures, which includes foreign objects left accidentally in patients, operating on the wrong site of the body, plus operative and postoperative complications.

In the first half of the year, TJC reviewed only 41 suicide events, compared to 96 for all of 2019 — that includes suicides in inpatient and emergency department settings as well as within 72 hours after discharge.

Despite the challenges of the year, TJC will continue to review and work with healthcare organizations to reduce sentinel events. Thomas promised the commission will be sensitive to the challenges facing hospitals and other healthcare organizations.

“Our patient safety specialists have been sensitive to the unprecedented stressors that healthcare organizations face because of the pandemic,” Thomas stated.

“Our department strives to be nimble and accommodating to meet the individualized needs of organizations as they manage competing priorities. We appreciate that health care organizations continue to find value in working with The Joint Commission to evaluate harm events and implement sustainable mitigation plans to prevent recurrences while managing these unfamiliar crisis situations.”

The statistics, as released by TJC for the first half of 2020, followed by all of 2019, by category were:

Category	1st 6 months 2020	All of 2019
Care management	165 events	311
Surgical/invasive	131	237
Unassigned	46	48
Suicide	41	96
Protection events	38	87
Environment	12	45
Products/medical devices	4	0

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.