Patient Safety Events Jumped in 2021

Reported safety events in 2021 were the highest since the data began being recorded in 2007.  According to The Joint Commission, " A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reachesa patient and results in any of the following:
– Death
– Permanent harm
– Severe temporary harm and intervention required to sustain life"

The accrediting body received 1,197 reports of sentinel events last year, 89 percent of which healthcare organizations voluntarily reported. In 2020, 809 total events were reported. This total had previously peaked in 2012, when 946 sentinel events were reported. 

The 10 most frequently reported sentinel events for 2021:

  1. Fall — 485 reported events
  2. Delay in treatment  — 97
  3. Unintended retention of a foreign object — 97
  4. Wrong surgical site — 85
  5. Patient suicide  — 79
  6. Assault/rape/sexual assault of a patient — 55
  7. Patient self-harm — 45
  8. Fire — 38
  9. Medication management — 35
  10. Clinical alarm response — 22

The reporting of these Sentinel or safety events is voluntary and The Joint Commission doesn't construe any factual conclusions from the gathered data other than 2021 witnessed a spike in these safety events.  These safety events are serious and have profound implications for the affected patient and the healthcare industry as a whole.  For the first six months of 2021, The Joint Commission reported the following:

  • 47% of sentinel events led to a patient’s death.
  • 24% led to unexpected additional care.
  • 11% led to severe temporary harm.
  • 6% led to permanent loss of function.
  • 2% led to permanent harm.
  • 2% led to a psychological impact

The report contains all voluntary reports of safety incidents for the first half of 2021 but some of the incidents reported date back to 1995.  While this skews the numbers for any individual year, the fact that 2021 saw the largest spike in safety events reported since 2007 is cause for alarm. 

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