I. Sentinel Event
In support of its mission to continuously improve the safety and quality of health care provided to the public, The Joint Commission in its accreditation process reviews hospitals’ activities in response to sentinel events. The accreditation process includes all full accreditation surveys and, as appropriate, for-cause surveys, and random validation surveys specific to Evidence of Standards Compliance (ESC).
A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Such events are called “sentinel” because they signal the need for immediate investigation and response.
The terms “sentinel event” and “error” are not synonymous; not all sentinel events occur because of an error, and not all errors result in sentinel events.
II. Goals of the Sentinel Event Policy
The policy has four goals:
1. To have a positive impact in improving patient care, treatment, and services and preventing sentinel events
2. 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 organizational culture),and on changing the hospital’s culture, systems, and processes to reduce the probability of such an event in the future
3. To increase the general knowledge about sentinel events, their contributing factors, and strategies for prevention
4. To maintain the confidence of the public and accredited hospitals in the accreditation process.