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. Careful investigation and analysis of Patient Safety Events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm. The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.
A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following:
- Permanent harm
- Severe temporary harm and intervention required to sustain life
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. Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission. Organizations benefit from self-reporting in the following ways:
- The Joint Commission can provide support and expertise during the review of a sentinel event.
- The opportunity to collaborate with a patient safety expert in The Joint Commission’s Sentinel Event Unit of the Office of Quality and Patient Safety.
- Reporting raises the level of transparency in the organization and promotes a culture of safety.
- Reporting conveys the health care organization’s message to the public that it is doing everything possible, proactively, to prevent similar patient safety events in the future.
Further, reporting the event enables “lessons learned” from the event to be added to The Joint Commission’s Sentinel Event Database, thereby contributing to the general knowledge about sentinel events and to the reduction of risk for such events. For more information call the Sentinel Event Hotline, 630-792-3700.
Goals of the Sentinel Event Policy
The policy has the following four goals:
- To have a positive impact in improving patient care, treatment, and services and in preventing unintended harm
- To focus the attention of a hospital that has experienced a sentinel event on understanding the factors that contributed to the event (such as underlying causes, latent conditions and active failures in defense systems, or hospital culture), and on changing the hospital’s culture, systems, and processes to reduce the probability of such an event in the future
- To increase the general knowledge about patient safety events, their contributing factors, and strategies for prevention
- To maintain the confidence of the public, clinicians, and hospitals that patient safety is a priority in accredited hospitals
An event is also considered sentinel if it is one of the following:
- Suicide of any patient receiving care, treatment, and services in a staffed around-theclock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED)
- Unanticipated death of a full-term infant n Discharge of an infant to the wrong family
- Abduction of any patient receiving care, treatment, and services
- Any staff-witnessed sexual contact as described above
- Admission by the perpetrator that sexual contact, as described above, occurred on the premises
- Sufficient clinical evidence obtained by the hospital to support allegations of unconsented sexual contact
- Any elopement (that is, unauthorized departure) of a patient from a staffed around the-clock care setting (including the ED), leading to death, permanent harm, or severe temporary harm to the patient
- Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups)
- Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the hospital†
- Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital
- Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure‡
- Unintended retention of a foreign object in a patient after an invasive procedure, including surgery§
- Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
- Prolonged fluoroscopy with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose