Sentinel event form 2025

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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.
The most common sentinel events are wrong-site surgery, foreign body retention, and falls. [2] They are followed by suicide, delay in treatment, and medication errors. The risk of suicide is the highest immediately following hospitalization, during the inpatient stay, or immediately post-discharge.
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.
Never events are mostly considered preventable. If a healthcare organization was able to follow patient safety best practices, the never event should never occur, the NQF definition states. Conversely, a sentinel event might not be preventable or foreseeable.
The list of Sentinel Events includes, but is not limited to: Stage 3, 4, and unstageable pressure ulcer. Patient fall with serious injury or death. Unanticipated death with 48 hours of treatment. Unanticipated death. Wrong site surgery.
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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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