Healthcare organizations and patients reported more than 1,400 serious adverse events to the Joint Commission in 2022, an increase from recent years, according to data released Tuesday.
Falls, delayed care and wrong-site surgeries continued to be the biggest contributors to severe patient harm and death, the Joint Commission concluded.
The sentinel events in the Joint Commission’s annual review only represent those voluntarily reported and these findings can’t be seen as a representation of industrywide trends, the accrediting organization said in a news release. The figures nevertheless offer a glimpse into patient harm at the 547 healthcare organizations that submitted adverse event reports for 2022.
Here are a few takeaways:
- The total number of reported sentinel events increased by 19% in 2022 compared with 2021, and by 78% compared with 2020. Most events were voluntarily self-reported to the Joint Commission by accredited or certified healthcare entities.
- Of the reported sentinel events, 20% were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional treatments or procedures.
- The number of reported events involving falls rose from 173 in 2020 to 611 in 2022. Last year, 40% were due to patients walking, 23% involved patients falling out of bed and 10% happened while patients used the restroom.
- The Joint Commission cited a lack of fall-risk assessments and inadequate communication between staff during care transitions as root causes for the increased number of falls.
- In the delayed treatment category, 46% of events were related to a delay in care, 38% to a missed diagnosis, 14% to an abnormal test result not being addressed and 2% to an incorrect diagnosis.
- Among the sentinel events related to treatment delays, 66% resulted in death, 17% in severe harm and 14% in permanent harm.
- Nearly 90% of reported sentinel events in 2022 occurred in hospital settings.
- In the home care setting, 43% of reported serious adverse events involved fires related to medical equipment.
- The top sentinel event in ambulatory care settings was wrong-site surgeries at 25% of reported events.
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