A “sentinel event” is one of the most serious patient safety incidents that can occur at a health care organization, resulting in death, permanent harm or severe temporary harm. The term is from The Joint Commission, a nonprofit body that accredits health care organizations, which works with organizations to address sentinel events and put steps in place to prevent them from recurring.
Sentinel events can include incidents such as surgery to the wrong site or wrong patient; medication errors resulting in death or serious harm; patient falls with severe injury; and unintended retention of a foreign object during a procedure.
Organizations accredited by The Joint Commission are required to report sentinel events. Each event requires what is known as a root cause analysis, a structured investigation to identify the factors that allowed the event to occur. The organization then develops and implements a corrective action plan with measurable changes.
The Joint Commission also publishes a Sentinel Event Alert newsletter highlighting types of sentinel and adverse events, their common causes, and recommended steps to reduce risk and prevent them.
Deeper dive
In January 2027, the Sentinel Events List will adopt the updated National Quality Forum Serious Reportable Events list, according to the Joint Commission. This will include three legacy workforce safety sentinel events:
- Physical assault of a staff member.
- Sexual abuse/assault of a staff member.
- Homicide of a staff member.
Other new events to be added include:
- Patient harm associated with an MRI-related thermal injury.
- Administration of radiotherapy to the wrong patient or wrong body region.
- Fire occurring during direct patient care caused by equipment used by the health care setting.
- Patient harm associated with the care of a neonate.
- Patient harm associated with unrecognized clinical deterioration.