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      • A sentinel event is "any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness". Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed, and that undesirable trends or decreases in performance are caught early and mitigated.


      Specific events requiring review


      Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof". They also include the following, even if death or major loss of function did not occur:

      Infant abduction
      Release of an infant to an incorrect family
      Unexpected death of an infant not born prematurely
      Severe neonatal jaundice
      Surgery mistakes (wrong body part, wrong individual)
      Objects left in a patient after surgery
      Rape at a healthcare facility
      Suicide at a healthcare facility, or within 72 hours of departure
      Receiving a blood transfusion of the wrong blood type
      Radiation therapy to the wrong part of the body
      Radiation therapy 25% or more above the planned dose
      Any radiation dose over 15 Gy or resulting in permanent soft tissue damage (ie. skin or organ necrosis).
      In addition to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis.


      Actions and reporting


      Participation is necessary by the leadership of TJC accredited healthcare organizations and by the persons closely involved in the systems under review. Causal factors are analyzed, focusing on systems and processes, not individual performance. Potential improvements, called an "action plan", are identified and implemented to decrease the likelihood of such events in the future. Each accredited organization is encouraged, but not required, to report any sentinel event to The Joint Commission. However, the organization is expected to prepare a root cause analysis and action plan within 45 calendar days of the event. In addition, healthcare organizations are required to notify the Food and Drug Administration (FDA) and device manufacturers within 10 days of a sentinel event caused by a medical device, according to the Safe Medical Device Act of 1990. Statistics of sentinel events are recorded and published by the FDA's MedWatch program.
      Advantages of reporting sentinel events to The Joint Commission are:

      Adding to the database with dissemination to other health care facilities, preventing other adverse events.
      Consultation with The Joint Commission on implementing the root cause analysis and action plan.
      Association with national accrediting body reassures the public that all steps are being taken to prevent a recurrence.


      Joint Commission actions


      After review of the accredited facility's report on the sentinel event, The Joint Commission issues an Official Accreditation Decision Report that may modify the organization's current accreditation status, assign an appropriate "measure of success", or a require follow-up survey within six months. A healthcare facility that fails to complete a root cause analysis of the sentinel event and action plan within the time frame can be placed on "Accreditation Watch" by the Joint Commission, a status that can be publicly disclosed. The Joint Commission disseminates "sentinel event alerts" identifying specific sentinel events, their underlying causes, and steps to prevent recurrence.
      Further nursing research is ongoing at a number of "magnet" hospitals in the United States, especially to reduce the number of patient falls that may lead to sentinel events.


      References




      External links


      TJC Sentinel Events Policy and Procedure

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    Sentinel Event - The Joint Commission

    The ultimate purpose of The Joint Commission’s accreditation process is to enhance quality of care and patient safety. Each requirement or standard, the survey process, the Sentinel Event Policy, and other Joint Commission initiatives are designed to help organizations reduce variation, reduce risk, and improve quality.

    Sentinel Event Policy and Procedures | The Joint Commission

    A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).

    Sentinel Event Data 2023 Annual Review - The Joint …

    31 Des 2023 · 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 January 1, 2023 through December 31, 2023.

    Sentinel Event Policy (SE) - The Joint Commission

    01 Jan 2025 · provide information on trends in the occurrence of the most reported sentinel event categories. Goals of the Sentinel Event Policy The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events.

    Sentinel Event Data Summary - The Joint Commission

    By identifying causes, trends, settings and outcomes of sentinel events, The Joint Commission can provide critical information in the prevention of sentinel events to accredited health care organizations and the public. Includes: Types of Sentinel Event; Settings of Sentinel Events; Sources for SE Identification; Sentinel Event Outcomes

    The Joint Commission Releases Sentinel Event Data on Serious …

    A sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm. Sentinel events are debilitating to both patients and healthcare providers involved in the event. The Joint Commission reviewed 1,441 sentinel events in 2022. The most prevalent sentinel event types were: Falls (42%) Delay in treatment (6%)

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    Sentinel Event Alert Newsletters | The Joint Commission

    Sentinel Event Alert newsletters identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes, and recommends steps to reduce risk and prevent future occurrences. The Joint Commission started publishing Sentinel Event Alerts in …

    The Joint Commission issues Sentinel Event Alert on surgical fire ...

    The Sentinel Event Alert also reviews related Joint Commission requirements and provides resources and references. The full alert is available on The Joint Commission and The Joint Commission Journal on Quality and Patient Safety websites. It may be reproduced if credited to The Joint Commission. ### About The Joint Commission

    Now available: 2023 Sentinel Event Data Annual Report

    15 Mei 2024 · The Sentinel Event Data Annual Report for 2023 is now available on The Joint Commission website, including a figure showing the trend of reported sentinel events by source from 2005-2023. From Jan. 1-Dec. 31, 2023, The Joint Commission reviewed 1,411 sentinel events. The most prevalent event types identified in 2023 include the following: Falls ...