MFP Sentinel Event - dch georgia 2025

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The 10 most frequently reported sentinel events for 2023: Unintended retention of foreign object 8% Assault//sexual assault/homicide 8% Delay in treatment 6% Suicide 5% Fire/burns 4% Medication management 2% Perinatal event 2% Self-harm 2%
Patient falls continue to be the leading sentinel event type reviewed since 2019. In 2023, there were 672 events classified as patient.
The Joint Commission designates events as sentinel because they require an immediate investigation and response. Accredited organizations are expected to respond to sentinel events with a thorough and credible root cause analysis [RCA] and action plan (The Joint Commission, 2013a, p. 12).
Below are the 10 most often reported sentinel events and the total for each. Wrong-site surgery: 310. Medication error: 291. Delay in treatment: 172. Patient fall: 114. Patient death or injury in restraints: 113. Assault, , or homicide: 89. Transfusion error: 73. Perinatal death/loss of function: 71.
The top three root causes of sentinel events have to do with patient assessment, orientation/training, and communication.
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Georgia Department of Community Health.

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