Sentinel Event Root Cause and Trend Data

The Joint Commission's Sentinel Event database contains information about serious adverse events, known as “sentinel events” that occur in accredited hospitals throughout the country. These adverse events include medication errors, wrong site surgery, suicide, operative and post-operative complications, and falls, among others. Hospitals submit to The Joint Commission reports of sentinel events,including root causes of the events and strategies to prevent the recurrence of the event. The information for these reports form the basis of the Sentinel Event database.

Inadequate communication between care providers or between care providers and patients/families is consistently the main root cause of sentinel events. Other leading root causes include incorrect assessment of a patient’s physical or behavioral condition and inadequate leadership, orientation or training.

 

The increasing number of sentinel events reported each year does not necessarily mean that more adverse events are occurring or that hospitals are becoming less safe. Rather, the increasing number is more likely to be due to more consistent reporting of these events. The following graphs illustrate total reported sentinel events and reviewed events by state. While the majority of sentinel event reports are from accredited hospitals, approximately 20 percent are from other accredited organizations, including nursing homes, office-based surgeries and laboratories.