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Unintended retention of objects after surgery tops most-reported sentinel events

Accreditation Insider, September 30, 2014

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Of the 394 sentinel events reviewed by The Joint Commission in the first half of 2014, unintended retention of a foreign object after surgery was the most frequently reported event, according to the October issue of Joint Commission Perspectives.

On the most frequently reported list, unintended retention of foreign objects was reported 57 times, followed by other unanticipated events resulting in death or loss of function (53); falls (44); suicide (39);  wrong-patient, wrong-site, or wrong procedure (35); delay in treatment (34); criminal event (assault/rape/homicide) (29); operative/postoperative complication (27); perinatal death/injury (17); and medication error (12).

Of the 8,275 incidents reviewed from 2004 through the first half of 2014, a total of 8,495 patients have been affected by the events, with 4,984 (58.7%) resulting in a patient’s death, 801 (9.4%) resulting in loss of function, and 2,710 (31.9%) resulting in unexpected additional care and/or psychological impact.

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