The Joint Commission found fires and burns were the most frequent sentinel events in the home in 2023.
 
These cases accounted for 40% of incidents in the home care setting, according to the 2023 Sentinel Event Data Annual Report, released May 15.
 
In a close second was falls, accounting for 37% of sentinel events in the home.
 
The sentinel event data represents aggregate data from comprehensive systematic analysis (typically a root cause analysis) received by the Joint Commission Office of Quality and Patient Safety from Jan. 1, 2023, through Dec. 31, 2023.
 
According to the report, sentinel events are defined as:
 
Fire, flame, or unanticipated smoke, heat, or flashes occurring during direct patient care caused by equipment operated and used by the organization. To be considered a sentinel event, equipment must be in use at the time of the event; staff do not need to be present.
 
Fall in a staffed-around-the-clock care setting or fall in a care setting not staffed around the clock during a time when staff are present resulting in any of the following:
  • Any fracture
  • Surgery, casting, or traction
  • Required consult/management or comfort care for a neurological (for example, skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib fracture, small liver laceration) injury
  • A patient with coagulopathy who receives blood products as a result of the fall
  • Death or permanent harm as a result of injuries sustained from the fall (not from physiologic events causing the fall)