A sentinel event is an unexpected incident that causes death or serious injury (physical and/or psychological). It's a term often employed by professionals in settings where there is a risk of death or injury, such as aviation, the criminal justice system, and healthcare.
So, what is a sentinel event in healthcare, exactly? In this article, we'll explore that question in detail, with definitions and examples to ensure your understanding of this serious healthcare issue. Then, we'll answer some of the most common questions regarding sentinel events to better help you keep your patients safe.
The Healthcare Sentinel Event: Definition and Examples
A sentinel is one who stands guard — their job is to alert everyone else to danger. By using this term, healthcare organizations signal that these events are meant to alert a systemwide failure that poses an ongoing threat if left unaddressed.
For a negative event to be categorized as sentinel, it must not only involve death or significant injury, but also must be separate from the original illness or medical condition of the affected person. For example, a non-ill patient presents to the hospital for knee surgery, but becomes septic with a hospital-acquired infection while inpatient.
Is it the same as a medical error, then? Not necessarily. A sentinel event can occur because of a medical error (such as a patient being given the wrong medication dose by accident), but they're not exclusively medical errors. Unlike a medical error, sentinel events can happen separate from clinical care, such as a patient committing self-harm while in the healthcare setting.
What Is a Sentinel Event in Healthcare? FAQ
Still wondering about the details, such as events that may occur in different healthcare settings? Let's further explore this serious issue by addressing some of the topic's most frequently asked questions. We'll also highlight some sentinel event examples in different care settings.
Is there a standard way to define sentinel event in the healthcare industry?
Yes. The term was designated by The Joint Commission (TJC) in a policy introduced in 1996 with the aim of helping facilities process and learn from serious adverse events. TJC maintains a Sentinel Events List which functions to clearly define sentinel events and set a standard for the industry.
What's the difference between a sentinel event and an adverse event?
A sentinel event is a subset of serious adverse events in healthcare. The distinction often comes down to whether it's related to medical management. Adverse events are typically associated with less severe consequences and are due to medical mismanagement. Sentinel events are always critical in nature and may happen due to safety breakdowns that are separate from medical management (like in the case of a patient grievously injuring a staff member).
How are they different from never events?
The distinction between a sentinel event vs. never event is often preventability. A sentinel event may occur due to reasons beyond medical management control, but a never event is almost always the result of clinical inattentiveness.
What are some types of sentinel events?
A few of the most commonly reported types of sentinel event cases include:
- Patient falls
- Treatment delays
- Unintentional retention of surgical objects
- Wrong site surgeries
- Patient death by suicide
- Instances of self harm
- Medical mismanagement
Patient falls consistently ranks in the top 10 sentinel events. For example, falls accounted for 46% of the sentinel healthcare events reported to TJC throughout 2024.
Who is responsible for reporting sentinel events?
Sentinel event reporting starts with either the responsible staff member or the first worker to identify the problem. The responsible or identifying party should immediately alert their department supervisor who must initiate the incident report documentation, triggering an investigation (sometimes called a root cause analysis) that should take place within 24 hours of the event's occurrence.
External reporting may be dependent on state-specific regulatory standards. In Florida, for example, a sentinel event at a long-term care facility must be reported within 15 days to the state health agency. TJC also strongly encourages voluntarily reporting events to their agency for transparency and to request their assistance with the involuntary root cause analysis process.
By sharing information about a sentinel event, healthcare facilities give other organizations a chance to learn and hopefully remedy similar systemic failures before they cause injury or death.
Can this type of healthcare event affect staff, or only patients?
The sentinel event definition usually identifies patients as the affected party. However, according to TJC's sentinel event policy, the term also applies to staff members who are grievously injured (or killed) while working in the healthcare setting.
What is the standard follow-up process for healthcare facilities?
All healthcare organizations should have a policy in place that dictates the follow-up for sentinel events so that responses are standardized and informed by research and best practice. A well-organized response should include:
- Immediate provision of harm-mitigating care for the patient.
- Disclosure of the event to the patient (and their family, per patient preference).
- Ongoing supportive measures for the patient and family.
- Involvement of the patient's care team, the associated department, and facility leadership in the organizational response.
- Initiation of a root cause analysis investigation within 24 hours of the incident.
- Thorough documentation of the event via a standardized sentinel event reporting form.
- Reporting to all necessary external accreditation and state agencies, and voluntarily to TJC.
- Comprehensive, system-wide reform based on investigative findings.
How can organizations prevent serious adverse events from occurring?
Healthcare facilities have been shown to benefit from standard, strategic approaches to patient safety, such as the Comprehensive Unit-Based Safety Program (CUSP) model's safety framework. In keeping with that model, leadership can help improve patient outcomes and avoid significant adverse events by:
- Establishing a culture where harm is unacceptable.
- Encouraging clear communication and valuing honest reporting of errors and/or near-miss events.
- Utilizing all safety resources, including electronic safety stopgaps and clinical safety tools such as procedural timeouts, fall risk guides, and staff safety huddles.
- Engaging staff and facility leaders to spearhead initiatives that continue to investigate quality concerns and safety indicators, using collaborative efforts to guide better policies and safety strategies.
What is an example of a sentinel event in the hospital setting?
Patient falls are an unfortunately common sentinel event in hospital settings. Up to 20% of patient falls cause bone fracture, soft tissue injury, or head trauma, and most are preventable with strong fall-prevention strategies in place.
What is an example of a sentinel event in the long-term care setting?
Senior citizens are at high risk for depression. A resident dying by suicide while residing in a long-term care facility would qualify a sentinel event, meaning the facility would likely have to report it and perform a root cause analysis.
What is an example of a sentinel event in the surgical setting?
One of the leading sentinel events in surgical settings is wrong-site surgery. For example, a patient presents for removal of their right kidney, but the surgical team removes the left kidney.
How can data about serious adverse events help quality improvement efforts?
Proper follow-up after an event with significant consequences can improve future safety measures and may also reduce potential liability for the responsible organization. Using the data from a serious adverse event also helps target reform initiatives to address the areas where breakdowns in safety were able to occur. It can help with tracking patterns in severe adverse events (like trends in the reasons behind patient falls) and align organizational culture with institutional values and goals.
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