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What is a Sentinel Event? A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.
A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event.
As in previous years, patient falls was the most reported sentinel event (n=672, 48%) in 2023. The remaining leading categories were wrong surgery (n=112, 8%), unintended retention of foreign object (n=110, 8%), assault//sexual assault/homicide (n=106, 8%), delay in treatment (n=81, 6%), and suicide (n=71, 5%).
Suicide of any patient receiving care or within 72 hours of discharge, unanticipated death of a full-term infant, discharge of infant to wrong family, abduction of any patient receiving care/services, , assault, any elopement, surgery at wrong site/person, burns during patient care, maternal death.
Such events are called sentinel because they signal the need for immediate investigation and response. Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission.
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