Sentinel Event Policy and Procedures
The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help health care organizations that experience serious adverse events improve safety and learn from those sentinel events.
The Sentinel Event Policy
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:
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Death
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Permanent harm
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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:
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The Joint Commission can provide support and expertise during the review of a sentinel event.
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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.
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Reporting raises the level of transparency in the organization and promotes a culture of safety.
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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:
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Patient Safety Topics
- Emergency Management
- Health Equity
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Infection Prevention and Control
- Infection Prevention and Control
- Central Line-Associated Bloodstream Infections Toolkit and Monograph
- Ambulatory Health Care Infection Prevention and Control
- Antimicrobial Stewardship
- Behavioral Health Care Infection Prevention and Control
- Catheter-Associated Urinary Tract Infections
- Central Line-Associated Bloodstream Infections
- Compendium of Strategies to Prevent Healthcare-Associated Infections
- Critical Access Hospital Infection Prevention and Control
- Dental
- Disinfection and Sterilization
- General Infection Prevention and Control
- Guidelines
- Hand Hygiene
- High Reliability and Infection Prevention
- Home Care Infection Prevention and Control
- Hospital Infection Prevention and Control
- Infection Prevention and Control Safety Alerts
- Infectious Disease Outbreaks and Response
- Influenza and Other Related Diseases
- Laboratory Infection Prevention and Control
- Legionnaires' Disease
- Multidrug-Resistant Organisms
- Nursing Care Center Infection Prevention and Control
- Respiratory Protection
- Sepsis
- Surgical Site Infections
- Vaccination
- Pain Management
- Patient Safety
- Report a Patient Safety Event
- Sentinel Event
- Suicide Prevention
- The Physical Environment
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Workplace Violence Prevention
- Workplace Violence Prevention
- Joint Commission Blog Posts
- Joint Commission Podcasts
- Joint Commission Presentations
- Joint Commission Research Resources
- Joint Commission Resources Newsletters
- Joint Commission Resources and OSHA Alliance
- Agency for Healthcare Research and Quality
- American Hospital Association
- American Nurses Association
- American Psychiatric Association
- American Psychiatric Nurses Association
- American Society for Healthcare Risk Management
- California Hospital Association
- Canadian Centre for Occupational Health and Safety
- CDC/National Institute of Occupational Safety and Health
- Crisis Prevention Institute
- Depression and Bipolar Support Alliance
- Emergency Nurses Association
- Federal Bureau of Investigation
- From the Field
- Government Accountability Office
- DHS/Healthcare and Public Health Sector Coordinating Council
- iAdvance Senior Care
- Implementing Strategies for Safer Healthcare Organizations Webinar
- Institute for Healthcare Improvement
- International Association for Healthcare Security and Safety
- Massachusetts Department of Mental Health
- Minnesota Department of Health
- National Safety Council
- Occupational Safety and Health Administration
- Office of the Assistant Secretary for Preparedness and Response
- Ontario Safety Association for Community and Healthcare
- Oregon Association of Hospitals & Health Systems
- Sentinel Event Alert and Quick Safety newsletters
- Standards Related Information
- U.S. Department of Veterans Affairs
- Washington State Department of Labor & Industries
- Willis Towers Watson