A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in rootcause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated. Contents * 1 Specific Events requiring review * 2 Actions and reporting * 3 Joint Commission actions * 4External links * 5 Notes |
Specific Events requiring review
Besides "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof", sentinel events also include the following, even if the outcome was not death or major permanent loss of function: * Infant abduction, or discharge to the wrong family. * Unexpected death of a full term infant. * Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter). * Surgery on the wrong individual or wrong body part. * Surgical instrument or object left in a patient after surgery or another procedure. * Rape in a continuous care setting. * Suicide in a continuous care setting, or within 72 hours of discharge. * Hemolytic transfusion reaction due to blood group incompatibilities. [2] * Radiation therapy to the wrong body region or 25% above the planned dose.
In additional to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system