Major contributing factors in the reported events included an absent or inadequate alarm system, improper alarm settings, alarm signals that were not audible in all areas, and alarm settings that were inappropriately turned off. According to the alert, alarm-related events are recognized as underreported and occur in all healthcare settings however, 94 of the reported events occurred in hospitals, with the majority of those events occurring in telemetry, intensive care, general medicine, or emergency department areas. Of the 98 alarm-related events that were reported to the Joint Commission’s sentinel event database between January 2009 and June 2012, 80 resulted in death, 13 in permanent loss of function, and 5 in unexpected additional care or extended stay. The sheer number of medical device alarm signals on some hospital units can cause some clinicians to become overwhelmed by information or desensitized or immune to the sounds, a condition known as “alarm fatigue,” which can have serious consequences to patient safety, states an April 8, 2013, Joint Commission Sentinel Event Alert. Aging Services Risk Quality and Safety Guidance.ECRI Permissions Agreement – Clinical Practice Guidelines.Our goal is to help prevent these types of adverse events from occurring again. “For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. “Covid-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” Kaafarani said in a statement accompanying the report. Health facilities stripped of Joint Commission accreditation could find their Medicare funding in jeopardy. The Joint Commission accredits and certifies more than 22,000 hospitals, health systems, facilities and programs in the U.S. Nearly 90% of sentinel events occurred in a hospital, the Joint Commission said. The Joint Commission, which reviewed more than 1,400 sentinel events last year, blamed “failures in communication” and healthcare providers not “consistently following policies” as the leading causes of sentinel events.

Joint commission sentinel event