An unexpected occurrence involving death or serious physical or psychological injury

Sentinel event means any unexpected occurrence involving death, serious psychological injury, serious property damage, or the risk thereof. The phrase, “or the risk thereof” includes any circumstance where the continuous or repeated exposure to substantially the same general conditions would carry a significant chance of a serious adverse outcome. Sentinel Events specifically include each of the following: (i) loss of life, (ii) serious injury to Court staff or Court users, (iii) physical damage or the eminent threat to the Facility resulting from fire or lightning, windstorm or hail, smoke, explosion, riot or riot attending a strike, civil commotion, aircraft or vehicle impact, vandalism, leakage or accidental discharge of water pipes of any kind, the weight of snow, ice or sleet, water damage, collapse, or sudden mechanical failure of mechanical equipment, (iv) unusual health patterns resulting from environmental contamination especially due to asbestos, mold, lead, pesticides, metals, or other agents that might be found in waste streams, in disposal sites, or other accessible locations. “Spill, Prevention, Control and Countermeasure Plan (SPCC)” Spill, Prevention, Control, and Countermeasures Plan (SPCC Plan) means plans developed to comply with Title 40 Part 112 Oil Pollution Prevention and Health and Safety Code Division 20 Section 25270.

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Subspecialty
Related Media
Keyword History
Specific events requiring review[edit]
Actions and reporting[edit]
Joint Commission actions[edit]
References[edit]
External links[edit]
What is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof serious injury including loss of limbs or function?
What is considered a sentinel event?
Why is it called a sentinel event?
Is death a sentinel event?

Definition

A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof.

Subspecialty

Keyword History

87%/2015
85%/2012

Sources

PubMed

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".[1] 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[edit]

Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof".[1] 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[2]
Radiation therapy to the wrong part of the body
Radiation therapy 25% or more above the planned dose

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.

Main Sentinel Events reported to the Joint Commission in 2015[3]

Type of event	Number of events
Unintended Retention of a Foreign Body	123(13.14%)
Wrong–patient, wrong-site, wrong-procedure	121(12.93%)
Suicide	98(10.47%)
Fall	95(10.15%)
Delay In Treatment	82(8.76%)
Op/Post-op Complication	82(8.76%)

Actions and reporting[edit]

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[edit]

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.[4]

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[edit]

^ a b https://www.pressganey.com/docs/default-source/default-document-library/hpi-white-paper---sec-amp-sser-measurement-system-rev-2-may-2011.pdf[bare URL PDF]
^ A fatal transfusion reaction must be reported within 7 days.
^ "Summary Data of Sentinel Events Reviewed by The Joint Commission" (PDF). www.jointcommission.org. 2016. Retrieved 2019-07-09.
^ Joint Commission on Accreditation of Healthcare Organizations: Sentinel Event Alerts

External links[edit]

TJC Sentinel Events Policy and Procedure

What is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof serious injury including loss of limbs or function?

The Joint Commission defines a sentinel event as an unexpected occurrence involving death, serious physical or psychological injury. The event can result in death, permanent harm, or severe, temporary harm. The term sentinel refers to a system issue that may result in similar events in the future.

What is considered a sentinel event?

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 health care providers involved in the event.

Why is it called a sentinel event?

An event can also be considered sentinel event even if the outcome was not death, permanent harm, severe temporary harm and intervention required to sustain life. See list below. Such events are called "sentinel" because they signal the need for immediate investigation and response.