sentinel event


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sentinel event

1. a type of clinical indicator used to monitor and appraise the quality of care, indluding events that require immediate attention.
2. an adverse event in health care delivery or other service, which either leads to or has potential to lead to catastrophic outcomes (for example, near miss), thereby often mandating initiation of emergency intervention or of preventive measures.
A term for a ‘headliner’ event that may cause an unexpected or unanticipated outcome, death or serious physical or psychological injury, or the risk thereof
Examples Suicide while a patient is under 24/7 surveillance; unexpected death of a full-term infant, infant abduction or discharge to the wrong family, rape, haemolytic transfusion reaction due to mismatched blood, surgery on the wrong patient or wrong body part

sentinel event

Health policy A term used by the JCAHO for a 'headliner' event that may cause an unexpected or unanticipated outcome or death, and trigger an investigation of a hospital's policies

sen·ti·nel e·vent

(sen'ti-nĕl ĕ-vent')
1. A type of clinical indicator used to monitor and appraise the quality of care, including events that require immediate attention.
2. nursing Any unexpected occurrence resulting in death, serious injury (e.g., physical, psychological, or other), or risk to the patient.
References in periodicals archive ?
The spokesperson for Princess Margaret Hospital (PMH) today (September 8) released the findings and recommendations of a root cause analysis investigation on a sentinel event, which was announced earlier by the hospital.
We often hear of whanau waiting outside the mortuary, separated from their loved one by walls and a bureaucratic technical process that categorises your loved one as a coroner's case, a Health and Disability Commissioner HDC case, a sentinel event, or a death in police custody," Pakeho said.
On March 1, 2017, The Joint Commission issued a sentinel event alert on the essential role of leadership in developing a safety culture (The Joint Commission, 2017a).
Patient Safety Systems Chapter, Sentinel Event Policy and RCA2 [cited 2016 Jan].
Safety and quality of patient care are dependent on teamwork, communication and a collaborative work environment, leading the commission to publish Sentinel Event 40, which mandates that commission-approved facilities establish policies and procedures to address behavioral issues.
7) Similarly in a 2013 Sentinel Event Alert, the Joint Commission specifically includes vaginal sponge retention as a reportable sentinel event that is a violation of patient safety and quality of care.
The Joint Commission (formerly the JCAHO-Joint Commission on Accreditation of Healthcare Organizations) recognizing the urgency of the suicide problem, issued a Sentinel Event Alert on February 24, 2016.
The Joint Commission (2011) issued a Sentinel Event Alert on healthcare worker fatigue and patient safety, listing the following impacts of fatigue:
The sentinel event of my life, apart from my decision to follow Christ, was the day I stopped my car at Duke University's East Campus to give several girls a ride to Wright Refuge, an emergency foster care facility, where we would spend the afternoon playing and tutoring the children.
The Joint Commission released its 40th Sentinel Event Alert way back on July 9, 2008.
As discussed in the National Institute of Justice (NIJ) Special Report Mending Justice: Sentinel Event Reviews, published in September 2014, some believe the criminal justice system lacks a feature that medicine, aviation and other high-risk enterprises see as critical: a way to account for tragic outcomes and using those lessons to reduce risk of recurrence.
In June 2008, the Joint Commission issued a Sentinel Event Alert describing "behaviors that undermine a culture of safety.