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Sentinel events must be reported by the facility or provider within one (1) business day from learning of the occurrence. A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury. Serious injury may include loss of limb or function.
Appropriate response includes conducting a timely, thorough, and credible root cause analysis; developing an action plan designed to implement improvements to reduce risk; implementing the improvements; and monitoring the effectiveness of those improvements.
A sentinel event involves serious injury or death. This statement is accurate. By definition, a sentinel event is associated with an unexpected occurrence that involves death or serious physical or psychological injury, or the likelihood thereof. Serious injuries include significant loss of function or quality of life.
10 most common sentinel events in 2023: Joint Commission Falls 48% Wrong surgery 8% Unintended retention of foreign object 8% Assault//sexual assault/homicide 8% Delay in treatment 6% Suicide 5% Fire/burns 4% Medication management 2%
Reporting raises the level of transparency in the organization and promotes a culture of safety. Reporting conveys the health care organizations message to the public that it is doing everything possible, proactively, to prevent similar patient safety events in the future.
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Timely reporting will promote early engagement with a patient safety specialist assigned to work with your organization. Contacting The Joint Commission following a sentinel event allows the health care organization to avail itself of the wealth of expertise and experience of its staff.

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