Preventable Medical Errors Rose 12% in 2024

In 1996, the Joint Commission adopted a formal Sentinel Event Policy to help health care organizations that experience serious adverse events improve safety and learn from those sentinel events. A sentinel event is defined by The Joint Commission as “a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).” ¹

The Joint Commission recently published its Sentinel Event Data 2024 Annual Review and the data is striking. Sentinel Event Data CY2023 Annual Summary Over the prior year there was a 12% increase in sentinel events reported to the Commission. The severity of harm reported from the results ticked upward: 21% ended in patient death, 49% in severe temporary harm and 21% in moderate harm. 

The data reveals some very concerning issues regarding patient care. Patient falls were the dominant cause of all sentinel events. There were 776 falls reported resulting in 503 severe injuries and 51 deaths. Most involved patients 70 years of age and older and involve walking, getting out of bed and toileting. 

Sentinel events involving wrong surgery increased by 13%. Of those, 68% involved wrong-site procedures with over one-half of those involving incorrect laterality. Retained foreign objects, with sponges being the most frequently retained objects, continue to be a significant event.

Across all of these events The Joint Commission observed the same repeated systemic issues: 

1. Failure to adhere to existing policies and procedures;
2. Breakdowns in communication and a lack of situational awareness during hand-offs, team briefings or emergencies;
3. Gaps in clinical competency or timely recognition of patient deterioration.

Reporting of sentinel events to The Joint Commission is largely voluntary and so it stands to reason that this data reflects and under-reporting of the true incidence. Nevertheless, the 2024 data is alarming and confirms that falls, failure to abide by safe surgical practices and recognition of patient deterioration remain significant issues in patient care today. 

¹ resources sentinel-event sentinel-event-policy-and-procedures – jointcommission