Vital Signs Blog

Blog: Patient suicides among top sentinel events hospitals reported in 2015

Objects left inside patients, wrong-site surgeries and patient suicides were the most frequent sentinel events reported to the Joint Commission in 2015, according to preliminary data provided to Modern Healthcare.

Since 1995 the accreditation body has collected reports of care-related issues that result in patients being harmed through a sentinel event database. The organization has also issued 55 alerts warning of concerns such as patient falls, unsafe use of technology, hospital-acquired infections and alarm fatigue.

This week the agency released a brief intended to help hospitals avoid the the most frequently reported lapse in 2015 (PDF). There were 115 reports of foreign objects unintentionally left inside patients after an operation.

It's evident that accredited organizations continue to struggle with that problem, which had dropped to No. 3 in 2013 after holding the No. 1 position for two years in a row.

The preliminary data show 110 reports of wrong-site surgeries and 95 reports of patients committing suicide in a clinical setting, making them the second and third most frequently reported events, a spokeswoman said in an e-mail.

Concerns about mental health were also raised this week by the U.S. Preventive Services Task Force. The group expanded its recommendations for depression screening, saying it is universally helpful for all U.S. adults over age 18, including pregnant and postpartum women.

The panel concluded that benefits of treating appropriate patients with antidepressants outweigh any potential medication side effects, such as the increased risk of suicidal behaviors, gastrointestinal bleeding and potential serious harms to fetuses.

The Joint Commission is analyzing its full dataset from 2015 and could not provide a number for how many total sentinel events were reported last year. But an analysis published this month (PDF) shows a total of about 600 in the first three quarters.

Other frequently reported events in that report include falls, medication errors, assaults and treatment delays that resulted in death or permanent loss of function for the patient.

The Joint Commission notes, however, that most sentinel events reported to the database are voluntary and therefore reflect only a small number of the actual events.


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