A sentinel event is an unexpected death or serious physical—including loss of limb or function—or psychological injury, or the risk thereof. “Risk thereof” means that, although no harm occurred this time, any recurrence would carry a significant chance of a serious adverse outcome.
Sentinel Event Alert is a newsletter published for accredited organizations, interested health care professionals, and the public that identifies specific types of sentinel events, describes their common underlying causes, and recommends steps to prevent future occurrences.
Information for an Alert comes from The Joint Commission’s sentinel event database, experts, and other organizations. The Joint Commission began publishing Sentinel Event Alert in 1998 in order to share “lessons learned” from its database and provide important information relating to the occurrence and management of sentinel events in health care organizations. Sentinel Event Alert has raised awareness in the health care community and the federal government about adverse events. Past issues are available on The Joint Commission website. Topics have included medication errors, wrong-site surgery, restraint-related deaths, blood transfusion errors, inpatient suicides, infant abductions, and fatal falls.
Accredited organizations should consider information in an Alert when designing or redesigning relevant processes and consider implementing relevant suggestions contained in the Alert or reasonable alternatives.