
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. If an organization wishes to self-report an event that is subject to review by JCI Accreditation, the organization can submit the report to JCI at.

infant abduction or an infant sent home with the wrong parents.Transplanting contaminated organs or tissues transmission of a chronic or fatal disease or illness because of infusing blood or blood products or.

wrong-site, wrong-procedure, wrong-patient surgery.major permanent loss of function unrelated to the patient’s natural course of illness or underlying.death that is unrelated to the natural course of the patient’s illness or underlying condition.Such events are called "sentinel" because they signal the need for immediate investigation and response.Įxamples of events that are considered a sentinel event that require a review, include but are not limited to: Severe temporary harm and intervention required to sustain lifeĪn 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.The Sentinel Event Policy explains how Joint Commission International partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.Ī sentinel event is a patient safety event that reaches a patient and results in any of the following:

The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help health care organizations that experience serious adverse events improve safety and learn from those sentinel events.Ĭareful 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.
