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Friday 1:37 CST, April 25, 2014

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Sentinel Event Policy and Procedures

June 10, 2013

In support of its mission to continuously improve the safety and quality of health care provided to the public, The Joint Commission reviews organizations’ activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced surveys and, as appropriate, for-cause surveys.

  • 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 “medical error” are not synonymous; not all sentinel events occur because of an error and not all errors result in sentinel events.


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