Sentinel Event Policy

Sentinel Event Policy (SE)
Careful identification, investigation, and analysis of patient safety events, as well as

strong corrective actions that provide effective and sustained system improvement, is
essential to reduce risk and prevent patient harm. The Sentinel Event Policy explains
how The Joint Commission partners with health care organizations that have
experienced a serious patient safety event to protect future patients, improve systems,
and prevent further harm.
Although organizations are not required to report sentinel events to The Joint
Commission, accredited organizations must have a policy detailing how the organization
addresses sentinel events. The specific requirements of that policy are included in the
“Leadership” (LD) and “Performance Improvement” (PI) chapters on E-dition® or in
the hard-copy Comprehensive Accreditation Manual. The organization must complete a
thorough comprehensive systematic analysis (most commonly a root cause analysis) to
determine why the event occurred. The organization must then create a corrective action
plan to prevent similar events from happening again, implement the plan, and monitor
its effectiveness.
All accredited organizations are encouraged to self-report potential sentinel events to
The Joint Commission to allow collaboration with the Office of Quality and Patient
Safety (OQPS). 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. Joint
Commission patient safety specialists can help analyze root causes, redesign processes,
and monitor performance improvement practices and other aspects of the sentinel event
process.
Self-reporting reinforces the organization’s message to the public that it is doing
everything it can to prevent a recurrence. Sharing information, particularly lessons
learned, with The Joint Commission enhances The Joint Commission’s Sentinel Event
Database, which may help other organizations prevent similar events. The more
organizations report their own sentinel events, the better and more meaningful sentinel
event statistics become. The Joint Commission sentinel event data identify not only the
Shading indicates a change effective July 1, 2024, unless otherwise noted in the What's New.
CAMLAB Update 1, July 2024 SE – 1
E-dition July 1, 2024, Release
◤Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing
relative frequency of different categories of sentinel events reported each year, they also
provide information on trends in the occurrence of the most reported sentinel event
categories.
Goals of the Sentinel Event Policy

The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals
that experience serious adverse events improve safety and learn from those sentinel
events. The Joint Commission’s Sentinel Event Policy has the following four goals:
1. To positively impact care, treatment, or services by helping health care organizations
identify opportunities to change their culture, systems, and processes to prevent
unintended harm
2. To help health care organizations that have experienced a sentinel event determine
and understand contributing factors (including underlying causes, latent conditions,
and active failures) and develop strategies to prevent or reduce such events in the
future
3. To increase the health care organization’s resilience by becoming a learning
organization
4. To maintain the confidence of the public, clinicians, and health care organizations in
the priority of patient safety in Joint Commission–accredited health care organiza-
tions
Identifying Sentinel Events

Sentinel events are a subcategory of adverse events. A sentinel event is a patient safety
event (not primarily related to the natural course of a patient’s illness or underlying
condition) that reaches a patient and results in death, severe harm (regardless of duration
of harm), or permanent harm (regardless of severity of harm).
Sentinel events are not only events that occur during the care and treatment of
individuals. Physical and verbal violence, abductions, and power failures are all potential
sentinel events that can affect the health care organization and its patients. The Joint
Commission considers the following list of events, though not comprehensive, to be
sentinel events if they occur under any Joint Commission–accredited health care
organization, although some of these events are unlikely to occur in certain health care
settings:*
*
Throughout this section, terms that are shown in boldface and italics are defined in the “Key
Terms” sidebar.
SE – 2 CAMLAB Update 1, July 2024
Sentinel Event Policy ◥
■ Death caused by self-inflicted injurious behavior if any of the following apply:

❏ While in a health care setting
❏ Within 7 days of discharge from inpatient services
❏ Within 7 days of discharge from emergency department (ED)
❏ While receiving or within 7 days of discharge from the following behavioral
health care services: Day Treatment/Partial Hospitalization Program (PHP)/
Intensive Outpatient Program (IOP), Residential, Group Home, and Tran-
sitional Supportive Living
■ Unanticipated death of a full-term infant
■ Homicide of any patient receiving care, treatment, and services while on site at the
organization or while under the care or supervision of the organization
■ Homicide of a staff member, visitor, or vendor while on site at the organization or
while providing care or supervision to patients
■ Any intrapartum maternal death
■ Severe maternal morbidity (leading to permanent harm or severe harm)†
■ Sexual abuse/assault of any patient receiving care, treatment, and services while
on site at the organization or while under the care or supervision of the organization
■ Sexual abuse/assault of a staff member, visitor, or vendor while on site at the
organization or while providing care or supervision to patients
■ Physical assault (leading to death, permanent harm, or severe harm) of any patient
receiving care, treatment, and services while on site at the organization or while
under the care or supervision of the organization
■ Physical assault (leading to death, permanent harm, or severe harm) of a staff
member, visitor, or vendor while on site at the organization or while providing care
or supervision to patients
■ Surgery or other invasive procedure performed at the wrong site, on the wrong
patient, or that is the wrong (unintended) procedure for a patient regardless of the
type of procedure or the magnitude of the outcome
■ Discharge of an infant to the wrong family
■ Abduction of any patient receiving care, treatment, and services
†
Ongoing vigilance to better identify patients at risk for severe maternal morbidity—and timely
implementation of clinical interventions consistent with evidence-based guidelines—are important
steps in the ongoing provision of safe and reliable care. Appropriate systems improvements can be
informed by identifying occurrences of maternal morbidity, reviewing the cases, and analyzing the
findings.
■ Any elopement (that is, unauthorized departure) of a patient from a staffed around-
the-clock care setting (including the ED), leading to death, permanent harm, or
severe harm to the patient
■ Administration of blood or blood products having unintended ABO and non-ABO
(Rh, Duffy, Kell, Lewis, and other clinically important blood groups) incompati-
bilities,‡ hemolytic transfusion reactions, or transfusions resulting in death,
permanent harm, or severe harm§
■ Unintended retention of a foreign object in a patient after an invasive procedure,
including surgery||
■ Severe neonatal hyperbilirubinemia (bilirubin >30 milligrams/deciliter)
■ Fluoroscopy resulting in permanent tissue injury when clinical and technical
optimization were not implemented and/or recognized practice parameters were not
followed#
■ Any delivery of radiotherapy to the wrong patient, wrong body region, unintended
procedure, or >25% above the planned radiotherapy dose
■ Fire, flame, or unanticipated smoke, heat, or flashes occurring during direct patient
care caused by equipment operated and used by the organization. To be considered
a sentinel event, equipment must be in use at the time of the event; staff do not
need to be present.
‡
If a clinical determination warrants the use of Rho(D) positive blood to a Rho(D) negative recipient
or uncrossmatched blood for emergent or lifesaving interventions, it would not be considered a
reviewable sentinel event.
§
Administration of blood or blood products where safety, potency, or purity has been compromised
while the blood product in question was in the laboratory’s control would be considered a sentinel
event. Source: Food and Drug Administration, Center for Biologics Evaluation and Research. 21 CFR
606.171.
||
The time period after an invasive procedure encompasses any time after the completion of final skin
closure, even if the patient is still in the procedural area or in the operating room under anesthesia. A
failure to identify and correct an unintended retention of a foreign object prior to that point in the
procedure represents a system failure, which requires analysis and redesign. It also places the patient at
additional risk by extending the surgical procedure and time under anesthesia. If a foreign object (for
example, a needle tip or screw) is left in the patient because of a clinical determination that the relative
risk to the patient of searching for and removing the object exceeds the benefit of removal, this would
not be considered a reviewable sentinel event. However, in such cases, the organization shall (1) disclose
to the patient the unintended retention and (2) keep a record of the retentions to identify trends and
patterns (for example, by type of procedure, by type of retained item, by manufacturer, by practitioner)
that may identify opportunities for improvement.
#
Source: Adapted from National Council on Radiation Protection and Measurements (NCRP):
Outline of Administrative Policies for Quality Assurance and Peer Review of Tissue Reactions
Associated with Fluoroscopically-Guided Interventions (https://ncrponline.org/wp-content/themes/
ncrp/PDFs/Statement_11.pdf) and the US Food and Drug Administration (FDA). Accessed Jan 11,
2024.
■ Fall in a staffed-around-the-clock care setting or fall in a care setting not staffed

around the clock during a time when staff are present resulting in any of the
following:
❏ Any fracture
❏ Surgery, casting, or traction
❏ Required consult/management or comfort care for a neurological (for example,
skull fracture, subdural or intracranial hemorrhage) or internal (for example, rib
fracture, small liver laceration) injury
❏ A patient with coagulopathy who receives blood products as a result of the fall
❏ Death or permanent harm as a result of injuries sustained from the fall (not
from physiologic events causing the fall)
The sidebar “Key Terms” provides definitions to help health care organizations navigate
the requirements of this policy.
Sidebar 1. Key Terms
fire A rapid oxidation process, which is a chemical reaction resulting in the evolution
of light and heat in varying intensities. Source: National Fire Protection Association.
NFPA 901: Standard Classifications for Incident Reporting and Fire Protection Data.
Quincy, MA: NFPA, 2016.
invasive procedure A procedure in which skin or mucous membranes and/or

connective tissue are incised or punctured, an instrument is introduced through a
natural body orifice, or foreign material is inserted into the body for diagnostic or
treatment-related purposes. Examples of invasive procedures include central line
and chest tube insertions, biopsies and excisions, and all percutaneous procedures
(for example, cardiac, electrophysiology, interventional radiology). Exclusions in-
clude venipuncture, which is defined as a collection of blood from a vein. Note: This
exclusion is still considered a patient safety event and should be reviewed by the
appropriate local quality and safety teams.
permanent harm An event or condition that reaches the individual, resulting in any
level of harm that permanently alters and/or affects an individual’s baseline health.
severe harm An event or condition that reaches the individual, resulting in life-
threatening bodily injury (including pain or disfigurement) that interferes with or
results in loss of functional ability or quality of life that requires continuous
physiological monitoring and/or surgery, invasive procedure, or treatment to resolve
the condition.
continued on next page
Sidebar 1. (continued)
severe maternal morbidity A patient safety event that occurs from the intrapartum
through the immediate postpartum period (24 hours), requiring the transfusion of 4 or
more units of packed red blood cells (PRBC) and/or admission to the intensive care
unit (ICU). Admission to the ICU is defined as admission to a unit that provides 24-
hour medical supervision and can provide mechanical ventilation or continuous
vasoactive drug support. Sources: American College of Obstetrics and Gynecology,
the US Centers for Disease Control and Prevention, and the Society of Maternal-
Fetal Medicine.
sexual abuse/assault Nonconsensual sexual contact of any type with an individual.

Sexual abuse includes, but is not limited to, the following:
■ Unwanted intimate touching of any kind, especially of the breasts, buttocks, or
perineal area
■ All types of sexual assault or battery, such as rape, sodomy, and coerced nudity
(partial or complete)
■ Forced observation of masturbation and/or sexually explicit images, including
pornography, texts, or social media
■ Taking sexually explicit photographs and/or audio/video recordings of an
individual and maintaining and/or distributing them (for example, posting on
social media); this would include, but is not limited to, nudity, fondling, and/or
intercourse involving an individual
Generally, sexual contact is nonconsensual in the following situations:

■ When the individual lacks the cognitive or legal ability to consent even though
appearing to want the contact to occur
■ When the individual does not want the contact to occur
Other examples of nonconsensual sexual contact may include but are not limited to
situations where an individual is sedated, is temporarily unconscious, or is in a coma.
An individual’s apparent consent to engage in sexual activity is not valid if it is
obtained from the individual lacking the capacity to consent, or consent is obtained
through intimidation, coercion, or fear, whether it is expressed by the individual or
suspected by staff. Any forced, coerced, or extorted sexual activity with an individual,
regardless of the existence of a preexisting or current sexual relationship, is
considered to be sexual abuse.
Organizations are required to conduct an investigation and protect an individual(s)

from nonconsensual sexual relations anytime the organization has reason to suspect
that the individual(s) does not wish to engage in sexual activity or may not have the
cognitive or legal ability to consent.
Sidebar 1. (continued)
Note 1: Reference for the above is the CMS State Operations Manual Appendix PP -
Guidance to Surveyors for Long Term Care Facilities.
Note 2: The first appearance of the terms in this sidebar are shown in boldface and
italics in the “Identifying Sentinel Events” section.
References
1. CMS State Operations Manual Appendix PP - Guidance to Surveyors for Long
Term Care Facilities. https://www.cms.gov/Regulations-and-Guidance/Guid-
ance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
2. Title 42 Chapter IV Subchapter G Part 483 Subpart B - Requirements for Long
Term Care Facilities. https://www.ecfr.gov/current/title-42/chapter-IV/subchap-
ter-G/part-483/subpart-B
In cases in which the health care organization is uncertain an event meets The Joint
Commission’s definition of a sentinel event, the event will be presumed to be a patient
safety event, requiring comprehensive analysis. In the spirit of collaboration and shared
learning, it is requested that this analysis be shared with OQPS.
All sentinel events must be reviewed by the health care organization and are subject to
review by The Joint Commission. Accredited health care organizations are expected to
identify and respond appropriately to all sentinel events (as defined by The Joint
Commission) occurring in the health care organization or associated with services that
the organization provides. An appropriate response includes all of the following:
■ A formalized team response that stabilizes the patient, discloses the event to the
patient and family, and provides support for the family as well as staff involved in
the event
■ Notification of organization leadership
■ Immediate investigation
■ Completion of a comprehensive systematic analysis for identifying the causal and
contributory factors
■ Strong corrective actions derived from the identified causal and contributing factors
that eliminate or control system hazards or vulnerabilities and result in sustainable
improvement over time
■ Timeline for implementation of corrective actions
■ Systemic improvement with measurable outcomes
Determining That a Sentinel Event Is Subject to

Review
To determine if an event is sentinel, the organization must electronically submit a self-
report (see the “Reporting a Sentinel Event to The Joint Commission” section). Based
on available information received about the event, a patient safety specialist from OQPS
will determine whether an event meets the definition of sentinel event (as described in
the “Identifying Sentinel Events” section). Any discrepancy in this determination will be
resolved through discussions between Joint Commission leadership and the organiza-
tion’s leadership.
Relationship to the Survey Process

When conducting an unannounced accreditation survey, the surveyor(s) evaluates the
health care organization’s compliance with the applicable standards, National Patient
Safety Goals, and Accreditation Participation Requirements. Surveyors are instructed
not to search for or investigate sentinel events during an accreditation survey or to
inquire about sentinel events that have been reported to The Joint Commission.
During the survey, the surveyor(s) will assess the organization’s compliance with sentinel
event–related standards (see Standard LD.03.09.01) and performance improvement
standards in the following ways:
■ Assess an organization’s performance improvement practices, such as its processes
for responding to safety events, adverse events, hazardous unsafe conditions, close
calls, and sentinel events
■ Review the health care organization’s process for responding to a sentinel event
■ Interview the organization’s leaders and staff about their expectations and
responsibilities for identifying, reporting on, and responding to sentinel events
If a potential serious patient safety event is newly identified during survey activities, the
surveyor will take the following steps:
■ Inform the organization’s CEO that the event has been identified
■ Inform the CEO the event will be reported to The Joint Commission for further
review and follow-up under the provisions of the Sentinel Event Policy
The surveyor makes no determination of whether the event is a sentinel event and does
not focus on or investigate the event further, nor are they authorized to review
comprehensive systematic analysis documents and determine credibility, thoroughness,
or acceptability. However, the surveyor may identify a Recommendation for Improve-

ment if the organization has not completed a comprehensive systematic analysis of the
event (including a corrective action plan) within 45 days of the event.
After the completion of on-site survey activities, once received by OQPS, a patient safety
specialist will contact the organization to explore the event and determine whether The
Joint Commission requires submission of a comprehensive systematic analysis. If so, the
organization will follow the steps described in the “Required Organization Response to
a Sentinel Event” section.
Required Organization Response to a

Sentinel Event
All sentinel events must undergo a comprehensive systematic analysis by the health care
organization, regardless of whether the events are reported to The Joint Commission. If
a reported sentinel event is determined to meet the criteria of this policy in a Joint
Commission–accredited organization, the health care organization is expected to do the
following:
■ Prepare a thorough and credible comprehensive systematic analysis and corrective
action plan within 45 business days of the event or of becoming aware of the event.
■ Submit its comprehensive systematic analysis and corrective action plan to The
Joint Commission, or otherwise provide its response to the sentinel event using an
approved methodology within 45 business days of the known occurrence of the
event for Joint Commission evaluation. Joint Commission OQPS staff will conduct
a collaborative review with the organization’s leadership or designee to determine
whether the analysis and action plan are acceptable. The alternative approaches to
this review appear in the “Submitting the Comprehensive Systematic Analysis and
Corrective Action Plan” section.
The fact that a health care organization has experienced a sentinel event will not impact
its accreditation decision. However, willful failure to respond appropriately to the
sentinel event could have such an impact. For instance, if the health care organization
fails to submit a comprehensive systematic analysis within an additional 45 days
following its due date, its accreditation decision may be impacted. In these instances,
patient safety specialists in OQPS, along with OQPS leadership, would recommend to
the executive leadership of The Joint Commission and the accreditation council to revise
the health care organization’s accreditation status.
Figure 1 provides a general timeline for the overall process.
Figure 1. This general timeline provides an overview of the sentinel event response process.
Reporting a Sentinel Event to The Joint

Commission
Each health care organization is strongly encouraged, but not required, to report to The
Joint Commission any patient safety event that meets the Joint Commission definition
of sentinel event. In fact, a vast majority of sentinel events reported to The Joint
Commission are self-reported by health care organizations that recognize the value of
working with OQPS staff. A health care organization benefits from self-reporting in the
following ways:
■ Getting support and expertise during the review of a sentinel event
■ Providing the health care organization an opportunity to collaborate with a patient
safety specialist who maintains the following qualifications:
❏ Masters-prepared clinician or human factors engineer
❏ Certified Professional in Patient Safety (CPPS) from the Institute for
Healthcare Improvement (IHI)
❏ Experienced in reviewing similar events
■ Raising the level of transparency in the health care organization, which promotes a
culture of safety
■ Conveying the message to the health care organization’s public that it is proactively
working to prevent similar patient safety events in the future
A health care organization can report a sentinel event or ask to clarify whether an event
meets the sentinel event definition through its Joint Commission Connect® extranet site.
Place the cursor over “Continuous Compliance Tools” and select “Self-Report Sentinel
Event” from the drop-down list. Follow the directions on screen to submit the report.
When a sentinel event is reported to The Joint Commission, OQPS will assign a patient
safety specialist. This is the organization’s main contact if there are questions about
completing the process.
Conducting a Comprehensive Systematic

Analysis
The health care organization must complete a comprehensive systematic analysis to
identify the causal and contributory factors to any known sentinel event. A
comprehensive systematic analysis is defined simply as a process for identifying basic or
causal factors underlying variation in performance, including the occurrence or possible
occurrence of a sentinel event. A root cause analysis, for example, is one common type
of comprehensive systematic analysis. The organization can determine its internal
process, tools, and methodologies to conduct such an analysis. Any comprehensive
systematic analysis should include a bibliography of recent evidence-based literature to
guide the organization in developing a strong corrective action plan (addressed in the
next section) with the use of evidence-based practices or tools.
Joint Commission staff use the analysis, which focuses on systems and processes, to
review the organization’s analysis and verify it is thorough and credible (see the “Review
of Comprehensive Systematic Analyses and Corrective Action Plans” section). The
organization’s selected comprehensive systematic analysis method should address the
questions from The Joint Commission’s Framework for Root Cause Analysis and
Corrective Actions.** There are a number of mandatory fields within the form which
must be completed by the organization. If the organization chooses to do so, it can
upload supporting documents with its submission.
A health care organization’s comprehensive systematic analysis should identify system
vulnerabilities so that they can be eliminated or mitigated. It should not focus on
individual health care worker performance, but should seek out underlying systems-level
causations that manifested in personnel-related performance issues.†† To help adhere to
these characteristics it is recommended, but not required, that organizations consider the
following guidelines when developing causative factor statements:‡‡
■ Clearly show the cause-and-effect relationship
■ Use specific and accurate descriptors for what occurred, rather than negative and
vague words
■ Include a preceding cause for any human errors or violations of procedure (that is,
do not consider them root causes or causal factors)
■ Classify a failure to act as a causal factor only when there is a preexisting duty to act
See the “Review of Comprehensive Systematic Analyses and Corrective Action Plans”
section for more detail on what is considered a thorough and credible analysis.
Developing a Corrective Action Plan

An end-product of the comprehensive systematic analysis is a corrective action plan. The
corrective action plan identifies the strategies that the health care organization intends to
implement to reduce the risk of similar events occurring in the future. When
**
The Joint Commission: Framework for Root Cause Analysis and Corrective Actions. https://
www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/
rca_framework_101017.pdf. Accessed Jan 11, 2024.
††
National Patient Safety Foundation. RCA²: Improving Root Cause Analyses and Actions to Prevent
Harm. Boston: National Patient Safety Foundation, 2015. Available with a membership at https://
ihi.org or at https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/en-
dorsed-documents-improving-root-cause-analyses-actions-prevent-harm.ashx. Accessed Jan 11, 2024.
‡‡
Department of Veterans Affairs, Veterans Health Administration. VHA Patient Safety Improvement
Handbook 1050.01. Mar 4, 2011. https://www.va.gov/VHApublications/ViewPublication.asp?
pub_ID=10209. Accessed Jan 11, 2024.
formulating a corrective action plan, the review team should analyze the strength of its
proposed solutions. An evidence-based tool, such as the VA’s National Center for
Patient Safety’s action hierarchy,§§ can help the team identify strong actions that provide
effective and sustained system improvement.
The organization should identify at least one intermediate or stronger action (as defined
in the action hierarchy) to eliminate or mitigate system hazards or vulnerabilities
identified in the comprehensive systematic analysis. The corrective action plan must
address the following:
■ Identifying corrective actions to eliminate or reduce system hazards or vulner-
abilities directly related to causal and contributory factors
■ Identifying who is responsible for implementing corrective actions
■ Determining timelines to complete corrective actions
■ Developing strategies to evaluate the effectiveness of the corrective actions
■ Developing strategies to sustain the change
The National Patient Safety Foundation (NPSF), now merged with IHI, provides
detailed guidance on developing effective corrective action plans in its report RCA²:
Improving Root Cause Analyses and Actions to Prevent Harm.||||
See the “Review of Comprehensive Systematic Analyses and Corrective Action Plans”
section for more detail on what is considered an acceptable corrective action plan.
Submitting the Comprehensive Systematic

Analysis and Corrective Action Plan
A health care organization that reports a sentinel event must submit a comprehensive
systematic analysis, including the resulting corrective action plan that describes the
health care organization’s risk reduction strategies as well as how the strategies will be
evaluated and measured to determine effectiveness. This information is submitted
electronically and will be reviewed in a conference call involving Joint Commission staff
§§
US Department of Veterans Affairs National Center for Patient Safety. 2021 Guide to Performing a
Root Cause Analysis. Figure 7. Action Hierarchy, pages 22–23. https://www.patientsafety.va.gov/docs/
RCA-Guidebook_02052021.pdf. Accessed Jan 11, 2024.
||||
National Patient Safety Foundation. RCA²: Improving Root Cause Analyses and Actions to Prevent
Harm. Boston: National Patient Safety Foundation, 2015. Available with a membership at https://
ihi.org or at https://www.ashp.org/-/media/assets/policy-guidelines/docs/endorsed-documents/en-
dorsed-documents-improving-root-cause-analyses-actions-prevent-harm.ashx. Accessed Jan 11, 2024.
and health care organization staff. These documents should not include the names of
organization staff or patients involved in the sentinel event or other protected personal
health information (PHI).
If the health care organization has concerns about sending the comprehensive systematic
analysis and supporting documents to The Joint Commission, it has several options for
a Joint Commission review of its response to the sentinel event. The Joint Commission
has four alternative approaches to a review of the organization’s response to the sentinel
event, as shown in Table 1.
Table 1. Options for a Joint Commission Review of

an Organization’s Response to a Sentinel Event
OPTION DESCRIPTION LOCATION OF REVIEW
Alternative 0 The organization submits its com- Scheduled conference call

prehensive systematic analysis
and corrective action plan docu-
ments through the organization’s
secure Joint Commission Connect
extranet site.
Alternative 1 A review of the comprehensive The Joint Commission head-
systematic analysis and corrective quarters or web conference
action plan documents brought by alternative
the health care organization’s staff
to Joint Commission headquarters,
which are then returned to the
health care organization on the
same day.
Alternative 2 A review of the comprehensive Health care organization or web
systematic analysis and corrective conference alternative
action plan documents by a Joint
Commission patient safety special-
ist at the health care organization.
Alternative 3 A review of the organization’s sen- Health care organization or web
tinel event response process and conference alternative
corrective action plan by a Joint
Commission patient safety special-
ist at the health care organization.
The patient safety specialist may
ask questions regarding the com-
prehensive systematic analysis but
will not review the document itself.
The patient safety specialist will,
however, review the corrective ac-
tion plan and relevant documen-
tation. For purposes of this review
activity, relevant documentation in-
cludes, at a minimum, any docu-
mentation relevant to the health
care organization’s process for re-
sponding to sentinel events and
the corrective action plan resulting
from the analysis of the sentinel
event. The corrective action plan
serves as the basis for determining
appropriate follow-up activity.
Table 1. (continued)
OPTION DESCRIPTION LOCATION OF REVIEW
Alternative 4 A survey of the health care organ- Health care organization

ization by a specially trained Joint
Commission surveyor limited to
the following activities:
a. Interviews and relevant docu-
mentation review (including, if ap-
plicable, the patient’s clinical re-
cord) to evaluate the following:
■ The process the organization
uses to respond to sentinel
events
■ The relevant policies and pro-
cedures preceding and follow-
ing the health care organiza-
tion’s review of the specific
event, sufficient to allow the
surveyor to consider the ad-
equacy of the health care or-
ganization’s response to the
sentinel event and its ability to
provide safe care, treatment,
or services
b. Tracer activity on the health
care organization’s management
functions relevant to the sentinel
event and the care, treatment, or
services under review
Alternatives 1, 2, and 3 can be performed via web-based video conferencing with a

patient safety specialist who is located at The Joint Commission while the organization’s
participants remain at the organization’s location (Web-Alternative). Or, the organiza-
tion can choose to have a patient safety specialist visit the facility or send a representative
to The Joint Commission. Alternative 4 is an on-site survey.
The Joint Commission must receive a request for review of an organization’s response to
a sentinel event using any of the alternative options within five business days of the self-
report of a sentinel event.
Alternatives 1 to 4 will result in a fee to the health care organization to cover the average
direct costs of the option. Fees can be located on the pricing page accessible from the
organization’s Joint Commission Connect extranet site.
The Joint Commission’s Response

Patient safety specialists from The Joint Commission assess the health care organiza-
tion’s response to the sentinel event against three criteria:
1. Thoroughness of the comprehensive systematic analysis
2. Credibility of the comprehensive systematic analysis
3. Acceptability of the organization’s corrective action plan
A Joint Commission patient safety specialist will provide consultation to the health care
organization if the response is unacceptable and will allow an additional 15 business days
beyond the original submission period for the organization to resubmit its response,
including revised corrective actions if necessary. If the response is still unacceptable, the
health care organization’s accreditation decision may be impacted.
Review of Comprehensive Systematic Analyses

and Corrective Action Plans
Joint Commission patient safety specialists review the comprehensive systematic analysis
and corrective action plans for thoroughness, credibility, and acceptability.
To be thorough, the analysis must do the following:
■ Repeatedly ask “Why?” until the analysis identifies the systemic causal factors
associated with each step in the sequence that led to the sentinel event
■ Focus on systems and processes, not solely on individual performance
■ Determine the human and other factors most directly associated with the sentinel
event and the process(es) and systems related to its occurrence
■ Use the analysis to help determine where redesign might reduce risk
■ Inquire into all areas appropriate to the specific type of event
■ Identify risk points and their potential contributions to this type of event
■ Determine potential improvement in processes or systems that would tend to
decrease the likelihood of such events in the future or determine, after analysis, that
no such improvement opportunities exist
To be credible, the analysis must do the following:
■ Be clear (understandable information)
■ Be accurate (validated information and data)
■ Be precise (objective information and data without internal inconsistencies)
■ Be relevant (focus on issues related or potentially related to the sentinel event)
■ Be complete (cover all causes and potential causes)

■ Be systematic (methodically conducted)
■ Possess depth (ask and answer all of the relevant “Why” questions and explain any
“not applicable” finding)
■ Possess breadth of scope (cover all possible systemic factors wherever they occur)
■ Reflect diverse perspectives (include a process owner or designee, a patient or family
member when appropriate, and individuals close to the process under review)##
To be considered acceptable, the corrective action plan must do the following:
■ Identify changes that can be implemented to reduce risk, or formulate a rationale
for not undertaking such changes
■ Identify, in situations in which improvement actions are planned, the following:
❏ Who (by title) is responsible for implementation
❏ When the action will be implemented (including any pilot testing)
❏ How the effectiveness of the actions will be evaluated
❏ How the actions will be sustained
❏ The point at which alternative actions will be considered if improvement
targets are not met
❏ At least one stronger or intermediate-strength action
All comprehensive systematic analysis and corrective action plans will be considered and
treated as confidential by The Joint Commission (see the “Handling Sentinel Event–
Related Documents” section below).
If The Joint Commission finds the analysis and action plan thorough, credible, and
acceptable, a patient safety specialist from The Joint Commission will notify the
organization and assign one or more or follow-up activities.
Follow-up Activities
After The Joint Commission has determined that a health care organization has
conducted a thorough comprehensive systematic analysis (for example, root cause
analysis) and developed a comprehensive corrective action plan, The Joint Commission
will notify the organization whether the analysis and action plan are acceptable and will
##
The Joint Commission does not require the active involvement of a senior leader in the day-to-day
work of the comprehensive systematic analysis team. However, the team should report to the senior
leader or designee, and the individual should be involved in deciding or approving the actions the
organization will take as a result of the comprehensive systematic analysis.
assign an appropriate follow-up activity. This will be a mutually agreed-upon

documentation of sustained improvement and reduction of risk, which may include one
or more measures of success (MOS) or a review of the sentinel event at the health care
organization.
Sentinel Event Measures of Success

The health care organization’s follow-up activity may be conducted through the sentinel
event measure of success (SE MOS) process. The organization will identify one or more
SE MOS—that is, one or more numerical or quantifiable measures (ideally with a
numerator and denominator), usually related to an audit, which determines if the
organization effectively sustained the planned corrective action(s). The organization will
track the measure for at least 120 days (or four months) and report its compliance to
The Joint Commission. The organization’s report, due on a mutually agreed-upon date,
should demonstrate whether the organization reached its identified SE MOS and is
sustaining compliance.
The health care organization’s accreditation decision may be impacted under the
following circumstances:
■ An SE MOS submitted on time does not meet pre-established levels of compliance
and a Joint Commission patient safety specialist requests an additional 120 days (or
four months) of data that still does not meet pre-established levels of compliance.
■ Submission of an SE MOS more than 90 days (or three months) after the mutually
agreed-upon date.
Optional On-Site Review of a Sentinel Event

The Joint Commission will generally not conduct an on-site review of a self-reported
sentinel event unless it determines that a potential ongoing Immediate Threat to Health
or Safety exists. An Immediate Threat to Health or Safety is a threat that represents
immediate risk and has or may potentially have serious adverse effects on the health or
safety of the patient. All potential Immediate Threats to Health or Safety are referred to
Joint Commission executive leadership for authorization to conduct an unannounced
for-cause survey. If an on-site survey is conducted, the health care organization will be
billed a sufficient charge, based on an established fee schedule, to cover the costs of
conducting such a survey. (See the “For-Cause Surveys” section in “The Accreditation
Process” [ACC] chapter of E-dition or the Comprehensive Accreditation Manual for
more information.)
Disclosable Information
If The Joint Commission receives an inquiry about the accreditation decision of a health
care organization that has experienced a sentinel event, the organization’s current
accreditation status will be reported in the usual manner without making reference to
the sentinel event. If the inquirer specifically references the particular sentinel event, The
Joint Commission will acknowledge that it is aware of the event and currently is
working or has worked with the organization through the sentinel event review process.
Handling Sentinel Event–Related Documents

The Joint Commission restricts access to any submitted comprehensive systematic
analysis and corrective action plan to specially trained staff in accordance with
procedures designed to protect the confidentiality of the documents.
The Joint Commission will retain any corrective action plan(s) resulting from the
analysis of the sentinel event long enough to serve as the basis for appropriate follow-up
activities, such as the SE MOS or other mutually agreed-upon documentation of
sustained improvement. After the organization implements the corrective action plan
and The Joint Commission verifies it meets the established levels of compliance, the
information contained in any electronically submitted analysis will be de-identified after
OQPS completes its review.
The Sentinel Event Database

The Joint Commission collects and analyzes aggregate data from the comprehensive
systematic analyses, corrective action plans, and follow-up activities in its Sentinel Event
Database. The Joint Commission develops and maintains the database in a manner that
excludes organization, caregiver, and patient identifiers.
Aggregate data relating to root causes and risk reduction strategies for sentinel events
that occur with significant frequency form the basis for future error-prevention advice
to health care organizations through Sentinel Event Alerts, National Patient Safety
Goals®, and other methods of information sharing. The information disseminated from
the Sentinel Event Database of The Joint Commission can help an organization identify
a problem or area for analysis. For example, organizations can learn about sentinel events
that occur with significant frequency, their root causes, and possible risk reduction
strategies through The Joint Commission’s Sentinel Event Alerts.
Overseeing the Sentinel Event Policy

The executive leadership of The Joint Commission is responsible for approval of this
policy and overseeing its implementation.
For more information about the Joint Commission’s Sentinel Event Policy, visit the
Joint Commission’s website at https://www.jointcommission.org/resources/patient-
safety-topics/sentinel-event/sentinel-event-policy-and-procedures/.

Sentinel Event Policy

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Sentinel Event Policy (SE)

Careful identification, investigation, and analysis of patient safety events, as well as

Goals of the Sentinel Event Policy

Identifying Sentinel Events

■ Death caused by self-inflicted injurious behavior if any of the following apply:

■ Fall in a staffed-around-the-clock care setting or fall in a care setting not staffed

Sidebar 1. Key Terms

invasive procedure A procedure in which skin or mucous membranes and/or

sexual abuse/assault Nonconsensual sexual contact of any type with an individual.

Generally, sexual contact is nonconsensual in the following situations:

Organizations are required to conduct an investigation and protect an individual(s)

Determining That a Sentinel Event Is Subject to

Relationship to the Survey Process

or acceptability. However, the surveyor may identify a Recommendation for Improve-

Required Organization Response to a

Figure 1 provides a general timeline for the overall process.

Reporting a Sentinel Event to The Joint

Conducting a Comprehensive Systematic

Developing a Corrective Action Plan

Submitting the Comprehensive Systematic

Table 1. Options for a Joint Commission Review of

OPTION DESCRIPTION LOCATION OF REVIEW

Alternative 0 The organization submits its com- Scheduled conference call

OPTION DESCRIPTION LOCATION OF REVIEW

Alternative 4 A survey of the health care organ- Health care organization

Alternatives 1, 2, and 3 can be performed via web-based video conferencing with a

The Joint Commission’s Response

Review of Comprehensive Systematic Analyses

■ Be complete (cover all causes and potential causes)

assign an appropriate follow-up activity. This will be a mutually agreed-upon

Sentinel Event Measures of Success

Optional On-Site Review of a Sentinel Event

Handling Sentinel Event–Related Documents

The Sentinel Event Database

Overseeing the Sentinel Event Policy

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