Sentinel event
Sentinel event
A Sentinel event (pronounced: sen-ti-nel e-vent) is a significant occurrence in the healthcare setting that results in unexpected patient harm or risk thereof. These events are often referred to as "never events" because they are incidents that should never occur in a healthcare setting.
Etymology
The term "sentinel" originates from the Latin word "sentinela", meaning a guard or watchman. In the context of healthcare, a sentinel event is so named because it signals the need for immediate investigation and response.
Definition
A sentinel event is defined by the Joint Commission as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. This includes events that are clearly identifiable and measurable, have a high potential for causing patient harm, and are often preventable.
Examples
Examples of sentinel events include unexpected death, serious physical or psychological injury, suicide, unanticipated adverse event in the use of a medical device, operation on the wrong patient or body part, and abduction of a patient.
Reporting and Analysis
The Joint Commission requires healthcare organizations to identify and respond to all sentinel events. An important part of this process is conducting a root cause analysis (RCA), which is a structured method used to analyze serious adverse events. The goal of the RCA is to identify underlying problems that increase the likelihood of errors while avoiding the trap of focusing on mistakes by individuals.
Related Terms
External links
- Medical encyclopedia article on Sentinel event
- Wikipedia's article - Sentinel event
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