What is a Sentinel Event from medical context?

A sentinel event 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 "or risk thereof" includes any process variation for which a reviewer determines that a near-miss of serious injury or death occurred.

Sentinel events are often the result of system failures, rather than individual errors. They can occur in any healthcare setting, including hospitals, clinics, nursing homes, and long-term care facilities.

Some examples of sentinel events include:

* Unanticipated death

* Serious injury, such as a fall or medication error

* Wrong-site surgery

* Patient abduction

* Fire or other disaster

Sentinel events are reported to state and federal agencies, which investigate the events and make recommendations for preventing similar events from happening in the future.

Healthcare organizations are required to have policies and procedures in place to prevent sentinel events and to respond to them if they do occur. These policies and procedures should include:

* Risk assessment and management

* Education and training of staff

* Quality improvement programs

* Incident reporting and investigation

By following these policies and procedures, healthcare organizations can help to prevent sentinel events and improve patient safety.