It partners with hospitals that have experienced a sentinel event in the investigation, analysis, and development of corrective action plans. In 1996, the Joint Commission instituted a formal sentinel event policy. Establish a timeline for the implementation of corrective actionsĪll healthcare organizations should have a policy for responding to a sentinel event.Strong corrective actions to eliminate the root cause and prevent similar future events.Root cause analysis (RCA) for identifying the causal and contributory factors.Notification to the hospital leadership.Provide support for the family and staff involved.Disclose the event to the patient and family.Hemolytic transfusion reactions due to major blood group incompatibilities are still reported with an incidence of 7-9 per year.Īn appropriate response to a sentinel event may include the following:

Fortunately, infant discharge to the wrong family has been reduced to zero. The risk of suicide is the highest immediately following hospitalization, during the inpatient stay, or immediately post-discharge. They are followed by suicide, delay in treatment, and medication errors. The most common sentinel events are wrong-site surgery, foreign body retention, and falls. More than three-fourths of them are voluntarily reported to the agency. The great majority occur in a medical/surgical hospital setting, followed by psychiatric hospitals (including psychiatric units and clinics) and emergency departments. Sentinel events occur in every healthcare setting. Since 2007, about 800 sentinel events are reported to the Joint Commission every year according to their summary data of sentinel events. All accredited hospitals are encouraged but not obligated to report to the Joint Commission every sentinel event. The hospital must review all sentinel events. Unanticipated severe maternal morbidity resulting in permanent or severe temporary harm.Fire during direct patient care caused by hospital equipment.Prolonged fluoroscopy with very high or inappropriate dose or to the wrong site.Severe neonatal jaundice (bilirubin >30 mg/dl).Surgery on the wrong individual or wrong body part.Hemolytic transfusion reaction due to blood transfusion with major blood group incompatibilities.Discharge of an infant to the wrong family.Unanticipated death during the care of an infant.Suicide during treatment or within 72 hours of discharge.Examples of sentinel events from the Joint Commission include the following:

Hospitals vary in their definitions, investigations, and reporting of sentinel events. Serious reportable events can be classified into the following categories: In 2013, the concept was expanded to include “harm events” to the staff, visitors, and vendors on the organization’s premises. The National Quality Forum defined the term serious reportable events as “preventable, serious, and unambiguous adverse events that should never occur.” These events are also termed as never events. Previously, sentinel events included events that occurred only to patients. The term sentinel refers to a system issue that may result in similar events in the future. Sentinel events are debilitating to both patients and health care providers involved in the event. The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, or severe temporary harm.

Joint commission sentinel event