Specific Events Requiring Review
Besides "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof", sentinel events also include the following, even if the outcome was not death or major permanent loss of function:
- Infant abduction, or discharge to the wrong family.
- Unexpected death of a full term infant.
- Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).
- Surgery on the wrong individual or wrong body part.
- Surgical instrument or object left in a patient after surgery or another procedure.
- Rape in a continuous care setting.
- Suicide in a continuous care setting, or within 72 hours of discharge.
- Hemolytic transfusion reaction due to blood group incompatibilities.
- Radiation therapy to the wrong body region or 25% above the planned dose.
In additional to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis.
Read more about this topic: Sentinel Event
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