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Did The Joint Commission Omit Misdiagnosis from Its Lists of Top 10 Sentinel Events for 2018 and 2019?

Though data on delays in treatment due to misdiagnosis have been collected by TJC since 2015, misdiagnosis is not listed among the reported top 10 sentinel events

Accurate diagnosis could be the most critical aspect of all healthcare. Without accurate diagnoses, doctors may be delayed in starting treatment for their patients. In other cases, ordering inappropriate clinical laboratory tests might contribute to a misdiagnosis.

Healthcare experts know that misdiagnoses take place far too often. In fact, the Society to Improve Diagnosis in Medicine (SIDM) recently formed a coalition of more than 50 healthcare providers and patient advocacy organizations to end preventable medical diagnostic errors. (See Dark Daily, “Society to Improve Diagnosis in Medicine Forms Coalition to Address Preventable Diagnostic Errors; Proper Use of Clinical Laboratory Test Is One Goal,” September 13, 2019.)

SIDM’s analysis revealed that “one in three malpractice cases involving serious patient harm is due to misdiagnosis.” And that, “Cancer, vascular events, and infection account for three-fourths of high-harm, diagnosis-related claims.” 

Therefore, it seems odd that misdiagnosis would not be front and center on the latest list of Sentinel Events from The Joint Commission (TJC), the non-profit organization that accredits more than 21,000 healthcare organizations on behalf of the federal Centers for Medicare and Medicaid Services (CMS). Was it omitted? Perhaps not.

What Is a Sentinel Event?

The Joint Commission adopted its formal Sentinel Event Policy in 1996 as a way to help healthcare organizations improve safety and mitigate future patient risk. TJC defines a sentinel event as a “patient safety event that reaches a patient and results in any of the following:

  • “death,
  • “permanent harm,
  • “severe temporary harm, and
  • “intervention required to sustain life.” 

TJC determines healthcare events to be “sentinel” when they “signal the need for immediate investigation and response.”

Misdiagnosis leading to preventable medical errors would seem to be a sentinel event, but it is missing from TJC’s list for the past two years. It’s not, however, missing from an earlier TJC list of preventable diagnostic errors.

Delay in Treatment Due to Misdiagnosis

A 2015 TJC advisory report on safety and quality issues in healthcare, titled “Preventing Delays in Treatment,” lists misdiagnosis among several reported events that led to delays in diagnosis that then led to patient harm or death.

In that report, TJC defines “delay in diagnosis” as “a non-optimal interval of time between onset of symptoms, identification, and initiation of treatment. A delayed diagnosis occurs when the correct diagnosis is delayed due to failure in or untimely ordering of tests (e.g., [clinical laboratory] work, colonoscopies, or breast imaging studies). Whether due to delay in diagnosis, misunderstanding of the disease, misdiagnosis, or failure to treat, delay in treatment can reduce the number of treatment options a patient can pursue.”

So, misdiagnosis was, at that time, an event the TJC collected data on and included in its advisor statements. But since then, it has been omitted from the list. What changed?

Recent Sentinel Events

Turns out, nothing really. Though misdiagnosis is not listed on TJC’s lists for 2018 and 2019, it is part of a more comprehensive list published by TJC in February titled, “Most Commonly Reviewed Sentinel Event Types.” That report offers more details on the listed sentinel events, and also includes a section drawn from TJC’s 2015 report on delays in treatment, which covers results due to misdiagnosis.

In March, TJC released its top-10 list of most frequently reported sentinel events reported in 2018. They include:

  • Falls
  • Unintended retention of a foreign body
  • Wrong-site surgery
  • Unassigned
  • Unanticipated events such as asphyxiation, burns, choking, drowning or being found unresponsive
  • Suicide
  • Delay in treatment
  • Product or device event
  • Criminal event
  • Medication error

Then, in August, TJC release a new report based on the 436 reports of sentinel events TJC received in the first six months of 2019. They include:

  • Anesthesia-related events
  • Care management events
  • Criminal events
  • Environmental events
  • Product or device events
  • Protection events
  • Suicide—emergency department
  • Suicide—inpatient
  • Suicide—offsite within 72 hours (these are defined in the Sentinel Event Policy)
  • Surgical or invasive procedure events

Following the release of its March sentinel events list, TJC noted that the components were typical when compared to previous years. 

“The trend for the most frequently reported sentinel events remains generally unchanged,” stated Gerard Castro, PhD, MPH (above), Project Director, Patient Safety Initiatives at The Joint Commission, in a PSQH analysis of the Joint Commission’s 2018 list of sentinel events. “Organizations should continue their work toward minimizing risks associated with these types of events, but also strengthen systems and processes that keep patients safe, such as reporting and learning from close calls, teamwork, and improving safety culture.” (Photo copyright: The Joint Commission.)

TJC’s website notes, however, that “fewer than 2% of all sentinel events are reported to The Joint Commission. Of these, 58.4% (8,714 of 14,925 events) have been self-reported since 2005. Therefore, these data are not an epidemiologic data set, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.”

Might that be because the healthcare organizations in the US accredited by the Joint Commission are “encouraged” to report sentinel events and not “required” to do so? This also allows accredited healthcare organizations to pick and choose which events to report to TJC.

If there is one easy conclusion to draw from all the information presented above, it is that the true rate of misdiagnoses—as well as other types of sentinel events—remains unknown. But what is equally true is that, step by step, the adoption and use of electronic health systems (EHRs), along with other digital tracking modalities, will make it easier for providers and healthcare policymakers to more accurately identify and classify instances of misdiagnoses.

When that happens and better data on misdiagnoses is available, it will be possible for medical laboratory professionals to use the methods of Lean and quality management to collaborate with physicians and other providers. The first step will be to identify the sources of misdiagnoses. The second step will be to use these quality improvement techniques to support providers in ways that allow them to reduce or eliminate the causes of diagnostic errors and misdiagnoses.

—JP Schlingman

Related Information:

Sentinel Event Statistics Released for 2018

Sentinel Events (SE)

Most Commonly Reviewed Sentinel Event Types

Preventing Delays in Treatment

Sentinel Event Statistics Released for First 6 months of 2019 with New Suicide Categories

TJC Releases Compliance and Sentinel Event Stats for First Half of 2018

Lab Quality Confab and Process Improvement meeting