Communication failures, policy noncompliance fuel jump in reported patient safety events, Joint Commission finds

Reports of serious patient safety events among healthcare facilities in 2022 rose 19% from 2021 with falls, the most common such event, rising nearly 27%, according to data reported to The Joint Commission and released Tuesday.

The Joint Commission warns that the majority of last year’s 1,441 patient safety events were voluntarily reported by accredited healthcare facilities and “no conclusions should be drawn” regarding broader trends based on its sample.

However, the commission’s investigation of each reported event found “failures in communication, teamwork and consistently following policies” were the primary drivers for these incidents, suggesting potential areas in need of greater attention as the industry transitions back from pandemic pressures.

“COVID-19 continued to present challenges to healthcare organizations throughout 2022, and we saw the number of sentinel events increase above pre-pandemic levels,” Haytham Kaafarani, M.D., chief patient safety officer and medical director at The Joint Commission, said in a release accompanying the report, which also noted a 78% increase in reported events from 2020 to 2022.

“For each sentinel event, a Joint Commission patient safety specialist worked with the impacted healthcare organization to identify underlying causes and improvement strategies. Our goal is to help prevent these types of adverse events from occurring again,” Kaafarani said.

The Joint Commission defines its sentinel events as patient safety events resulting in death, permanent harm or severe harm. These events can include, for example, suicide of any patient receiving care, abuse or assault of a patient while receiving onsite care, intrapartum maternal death or an unintended surgery or other invasive procedure.

Nine in 10 of the 1,441 events were reported voluntarily by an accredited healthcare facility with the remainder reported by employees or patients and their families.

A fifth of the events were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional care or an extended stay, according to the report.

Falls were once again the most common event type and comprised 42% of the total, according to the report. Among those 611 events, 5% resulted in death and 70% severe harm to the patient. Two in 5 falls occurred while ambulating, 23% were a fall from a bed and 10% occurred while toileting.

Behind falls, delay in treatment (6%), unintended retention of a foreign object (6%), wrong surgery (6%) and suicide (5%) were the most common sentinel events.  

Eighty-eight percent of the reported events occurred in a hospital. Among these, 45% were falls, 7% were unintended retention of foreign object and 6% were wrong surgeries.

Within behavioral health settings, patient suicide (23%) led as the most frequent event type, followed by falls (18%) and delays in treatment (16%). Within home care settings, the leading events were fires (43%) and patient falls (20%), while ambulatory settings most often saw wrong surgeries (25%) and patient falls (22%).

The Joint Commission’s sample, though voluntary, examines a more recent period than those reported to the Centers for Medicare & Medicaid Services or patient safety watchdog the Leapfrog Group.

The latter’s most recent report combines data from summer 2018 to full-year 2022 depending on the measurement category. It broadly noted patient safety gains among hospitals during the past decade, including more than 25% reductions in patient fall and injury incidents as well as unintended retention of a foreign object between 2010 and 2019.