In support of its mission to improve the quality of health care provided to the public, The Joint Commission includes the review of organizations' activities in response to sentinel events in its accreditation process, including all full accreditation surveys and random unannounced 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. For more information see Sentinel Event Policy and Procedures.