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Joint Commission Updates Sentinel Event Statistics



The Joint Commission has investigated 6,782 of the sentinel events reported from January 1995 through March 31, 2010. A total of 6,920 patients have been affected by sentinel events during that time frame, with 67%—4,642 patients—resulting in patient death.

2 comments on "Joint Commission Updates Sentinel Event Statistics"
Jim best (4/12/2012 at 10:00 PM)

As per my previous blog I have an update. After meeting with JAG, IG, DDEAMC lawyer Mr. Shohulz am Ns hospital commander Col. Castle I was beyond frustrated. So I called the JACHO hotline to get information for myself. I learned the death of a 10 week old infant two days after a well baby appointment by an OB/GYN, yes not a GP or pediatrician but an OB/GYN somehow doesn't warrant a JACHO sentinel event report. My intuition was correct ,, no report and now it's to late to file one. I firmly believe they buried this case in hopes of it going away. my grandson Jakob suffocated as his lungs filled with inflammation crushing his alveolar sacs and they said he was healthy and gave him his immunizations. So be careful parents and follow your instincts , not the opinion of an unqualified doctor who rushes a physical. God bless our warriors whom stand the wall and the families who wait for them.
jim best (3/25/2012 at 8:32 PM)

My grandson died 9/20/2007 after being seen 9/17/2007 att DDEAMC Ft.gorndon Ga. for well baby apt. Jakob Wright Richardson 10weeks old had been seen 3 prevoius times for respiratory infection. His mother staying with myself and her ,other a sher husband was in Iraq, was told jakob had a cold , she was an inexperienced mother and he would be fine. On 9/17/2007 my wife virginia, went to the apt with her. the attending did a rushed exam as they were the last apt. of the day. this was a stayed fact. My wife . a experienced EMT with both militiary and civil srevice experience discussed the raulingg in his chest, latargiaa etc. Yhe doc insisted he was fine fine and while listening to concerns gave Jakob his immunizations. He passed away at home, found in his crib, in the nursury . After a investigation and post mortem exam he had a COD xof chronic diffuse lymphocytic interstital pneumonitis, with the opinion he was symptomatic and in resp. distress on 9/17/007 when he was seen by OB/GYN Chad Alan Asplund. while i consider this a reportable sentinal event and a risk management issue , DDEAMC hazs been less than forthcoming with info on a report or if even one was written. While Dr. splund has two previous reprimandes in 2004 and 2005 I see nothing in the latest Ga medical examiners board meeting minutes. I would be interested in knowing if DDEAMC filed a report as mandaeted by JACHO in this case or not. The IG stated it may not have required a report becuse the i fant passed away at home and not in the hospital. I believe that only exasterbates rhe fact that due to negligance in diagnositc testing and protocol ie xray, rsv swab, pulse ox level, of pulmonqry functions and obseravtory respiration counts, and visuality he was not not admitted because he was inproperly examined and the pneumonitis overlooked, leading to his death at our home. His father a solider in combat held his son for the first time at a funeral home, and they feel this didnt warrent a risk management assessment. I feel they failed in not havimpng him exami ed by a peds doc, they failed to follow through with the family after the deatj and I personally believe they buried the case by not filing a report and that is why they wont say one was filed.