The Joint Commission encourages organizations to report any sentinel event, but it’s not required. An “action plan” should be put in place for potential improvements to decrease the chance of the event happening again. Causal factors need to be analyzed, focusing on the system holistically. Should a sentinel event occur, any accredited healthcare organization must have a process to respond. Standards Must Be in Place to Respond to a Sentinel Event Accredited organizations are required to define sentinel events for their own care system and implement monitoring procedures and a process for root cause analysis. The Joint Commission identifies sentinel events in its accreditation policies to assist with root cause analysis and the development of new preventive measures. The Joint Commission’s mission is “ to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” 2 The Joint Commission defines a sentinel event as an unanticipated event in a healthcare setting resulting in death or serious injury, physical or psychological, not related to natural causes or the patient’s illness. To ensure that healthcare organizations have a high-reliability culture, the Joint Commission Center for Transforming Healthcare published a report, “Sentinel Event Alert 60: Developing a Reporting Culture: Learning from Close Calls and Hazardous Conditions.” 1 The Joint Commission issued this report to encourage a reporting culture where swift action is taken to remedy unsafe conditions. Administrators are too, especially when those actions include reacting to a safety concern raised by an employee. Each staff member is responsible for their own actions. Unanticipated severe maternal morbidity resulting in permanent or severe temporary harmĬopyright © 2023, StatPearls Publishing LLC.In any healthcare environment, patient safety is always top of mind. Prolonged fluoroscopy with very high or inappropriate dose or to the wrong siteįire during direct patient care caused by hospital equipment 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 Unanticipated death during the care of an infantĭischarge of an infant to the wrong family 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. Previously, sentinel events included events that occurred only to patients. 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. 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.
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