Sentinel Event Policy and Procedures

The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events. Careful 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. The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.

A sentinel event is a Patient Safety Event that reaches a patient and results in any of the following:

• Death

• Permanent harm

• Severe temporary harm and intervention required to sustain life 

An 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. See list below. 

Such events are called "sentinel" because they signal the need for immediate investigation and response. Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission. Organizations benefit from self-reporting in the following ways:

• The Joint Commission can provide support and expertise during the review of a sentinel event.

• The opportunity to collaborate with a patient safety expert in The Joint Commission’s Sentinel Event Unit of the Office of Quality and Patient Safety. 

• Reporting raises the level of transparency in the organization and promotes a culture of safety.

• Reporting conveys the health care organization’s message to the public that it is doing everything possible, proactively, to prevent similar patient safety events in the future.

Further, reporting the event enables “lessons learned” from the event to be added to The Joint Commission’s Sentinel Event Database, thereby contributing to the general knowledge about sentinel events and to the reduction of risk for such events.

Sentinel Event Policy and Procedures by Accreditation and/or Certification Program: 

• Ambulatory Health Care
• Behavioral Health Care
• Critical Access Hospital
• Home Care
• Hospital
• Laboratory
• Nursing Care Center
• Office-Based Surgery