2. Sentinel Event
Unexpected/unanticipated outcome
• Death
• Serious physical/phsychological injury or risk
• Examples:
– Loss of limb or function
– Patient on suicide watch commits suicide
– Unexpected death of full-term infant
– Infant abduction
– Infant discharged to wrong family
– Rape
– Reaction to mismatched blood
– Surgery on wrong patient/wrong body part

3. Difference Between Medical Error &
Sentinel Event
Medical Error: Sentinel Event:
– 44,000 and 98,000 Americans die – Death
each year – Physical/phsychological injury or risk
• Loss of limb or function
• Common Medical Errors • Suicide
– Incorrect administration of
• Rape
medication
• Infant death
– Dosage or route of
administration • Infant discharged to wrong parents
– Failure to prescribe or administer • Surgery on wrong patient, or body part
correct drug • Incorrectly matched blood transfusion
– Use of outdated drugs – 1,900 sentinel events reviewed by the Joint
– Failure to observe correct time Commission since January 1995
– Lack awareness of adverse – Patient suicide accounted for 16.5% of the errors
effects.
– Operative/post-operative complication – 12.3%
– Hard to read handwritten orders
– Different drugs – Wrong-site surgery – 11.7
– Drug allergies
– Medication error – 11.5

4. Sentinel Event Policy
• To have a positive impact in improving patient care, treatment, and
services and preventing sentinel events
• To focus the attention of a disease-specific care program that has
experienced a sentinel event
• understanding contributed factors to an event (such as underlying
causes, latent conditions, and active failures in defense systems or
organizational cultures)
• disease-specific care program’s systems, culture, and processes to
reduce the probability of such an event in the future
• To increase the general knowledge about sentinel events, their
contributing factors, and strategies for prevention
• To maintain the confidence of the public and certified programs in the
certification process

5. Expectations for Organizations
• Reporting:
– Root Cause Analysis
• Process to identify basic or causal factors of
sentinel events current or in future
– Action Plan
• Plan to identify strategies to implement
reduced risk of sentinel events
– Survey Process
• Evaluate the facilities compliance with
applicable standards
• Score performance

6. Sentinel Event is Identified:
• Surveyor reporting steps:
– Inform the CEO
• Sentinel event identified
• Reported to Joint Commission for review and
follow up
– Review process for responding to sentinel event
– Interview leaders
– Get examples of root cause analysis
» Examples can include closed cases or a near
miss

7. In Summary
• Sentinel Event: • Reporting:
– Unexpected – Classify and respond to sentinel
• Death event
• Physical/phsychological injury or risk • Root cause analysis
– Loss of limb or function • Action plan
– Suicide • Implement improvements
– Rape
– Infant death • Medical Error
– Infant discharged to wrong parents – Incorrect administration of medication
– Surgery on wrong patient, or body • Dosage or route of administration
part
• Failure to prescribe or administer
– Incorrectly matched blood
transfusion correct drug
• Use of outdated drugs
• Policy:
• Failure to observe correct time
• Improving
• Patient care • Lack awareness of adverse effects.
– Hard to read handwritten orders
• Treatment
– Different drugs
• Services
– Drug allergies
• Preventing sentinel events
• Focus on disease specific care
• Increase knowledge