Sentinel Event

The term sentinel event was created by the Joint Commission on Accreditation of Healthcare Organizations [Page 502](JCAHO). It is an unexpected occurrence involving death or serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function. The phrase “risk thereof” includes any process variation for which a recurrence would carry a significant chance of serious adverse outcome. Said differently, a sentinel event is an event that has resulted in an unanticipated death or major, permanent loss of function not related to the natural course of a patient's illness or underlying condition. The phrase “major permanent loss of function” means sensory, motor, physiologic, or intellectual impairment not present on admission and requiring continued treatment or lifestyle change. When major, permanent loss of function cannot be immediately determined, reporting is not expected until either the patient is discharged with continued major loss of function or two weeks have elapsed with persistent major loss of function, whichever occurs first. A distinction is made between an adverse outcome that is related to the natural course of the patient's illness or underlying condition and a death or major permanent loss of function that is associated with the treatment or lack of treatment of that condition. JCAHO considers the following to be mandatory sentinel events (even if the outcome is not death or permanent loss of function):

• Patient suicide or attempted suicide with serious injury in a setting where the patient is housed around the clock, or death, or serious injury following elopement from a hospital setting. An “elopement” is an unauthorized and unexpected patient departure from a facility.
• An infant abduction or discharge to the wrong family. An abduction is when a child has been taken from the facility without the knowledge and approval of the patient's physician and parent or legal guardian. Discharge to the wrong family occurs when a child and/or parents are misidentified. This most often occurs with newborns, when proper identification processes have not been initiated or maintained. An example is misplacement of identification bands, resulting in patient misidentification.
• Rape of a patient. This is a legal definition and differs according to state. Consult legal counsel to determine the strict legal interpretation of the term (for example, New York State Penal Law, Sections 130.35, 130.00, and 130.25, specifies definitions of first-, second-, and third-degree rape).
• Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibility.
• Surgery on the wrong patient or wrong body part.