What Is a Sentinel Event in Healthcare? Overview and FAQ

A sentinel event is an unexpected incident that causes death or serious injury — physical and/or psychological. It’s a term often employed by professionals in settings where there is a risk of death or injury — like aviation, the criminal justice system, and healthcare.

So, what is a sentinel event in healthcare, exactly? In this article, we’ll explore that question in detail, with definitions and examples to ensure your understanding of this serious healthcare issue. Then, we’ll answer some of the most common questions regarding sentinel events to better help you keep your patients safe.

The Healthcare Sentinel Event: Definition and Examples

A sentinel is one who stands guard — their job is to alert everyone else to danger. By calling an occurrence of significant harm a sentinel event, healthcare organizations signal that these events are meant to alert a systemwide failure that poses an ongoing threat if left unaddressed.

For a negative outcome to be categorized as a sentinel event, it must not only involve death or significant injury, but also must be separate from the original illness or medical condition of the affected person. For example, a non-ill patient who presents to the hospital for knee surgery, but becomes septic with a hospital-acquired infection while inpatient.

Is a sentinel event a medical error, then? Not necessarily. A sentinel event can occur because of a medical error (such as a patient being given the wrong medication dose by accident), but they’re not exclusively medical errors. Unlike a medical error, sentinel events can happen separate from clinical care, such as a patient committing self-harm while in the healthcare setting.

What Is a Sentinel Event in Healthcare? FAQ

Still wondering about the details, such as What are sentinel events that may occur in different healthcare settings? Let’s further explore this serious issue by addressing some of the topic’s most frequently asked questions. We’ll also highlight some sentinel event examples in different care settings.

What’s the difference between a sentinel event and an adverse event?

A sentinel event is a subset of serious adverse events in healthcare. The distinction often comes down to whether it’s related to medical management. Adverse events are typically associated with less severe consequences and are due to medical mismanagement. Sentinel events are always critical in nature and may happen due to safety breakdowns that are separate from medical management (like in the case of a patient grievously injuring a staff member).

So-called never events are a subset of sentinel events. The distinction between a sentinel event vs. never event is often preventability. A sentinel event may occur due to reasons beyond medical management control, but a never event is almost always the result of clinical inattentiveness.

What are some types of sentinel events?

A few of the most commonly reported types of sentinel event cases include:

• Patient falls.
• Treatment delays.
• Unintentional retention of surgical objects.
• Wrong site surgeries.
• Patient death by suicide.
• Instances of self harm.
• Medical mismanagement.

Who is responsible for reporting sentinel events?

Sentinel event reporting starts with either the responsible staff member or the first worker to identify the problem. The responsible or identifying party should immediately alert their department supervisor who must initiate the incident report documentation, triggering an investigation (sometimes called a root cause analysis) that should take place within 24 hours of the event’s occurrence.

External reporting may be dependent on state-by-state regulatory standards. In Florida, a sentinel event at a long-term care facility must be reported within 15 days to the state health agency. The Joint Commission on Accreditation of Hospital Organizations (JCAHO) also strongly encourages voluntarily reporting events to their agency for transparency and to request their assistance with the involuntary root cause analysis process.

Can a sentinel event affect staff, or only patients?

The sentinel event definition usually identifies patients as the affected party. However, according to JCAHO sentinel event policy, the term also applies to staff members who are grievously injured (or killed) while working in the healthcare setting.

What is a sentinel event standard follow-up process?

All healthcare organizations should have a policy in place that dictates the follow-up for sentinel events so that responses are standardized and informed by research and best practice. A well-organized response should include:

• Immediate provision of harm-mitigating care for the patient.
• Disclosure of the event to the patient (and their family, per patient preference).
• Ongoing supportive measures for the patient and family.
• Involvement of the patient’s care team, the associated department, and facility leadership in the organizational response.
• Initiation of a root cause analysis investigation within 24 hours of the incident.
• Thorough documentation of the event via a standardized sentinel event reporting form.
• Reporting to all necessary external accreditation and state agencies, and voluntarily to JCAHO.
• Comprehensive, system-wide reform based on investigative findings.

How can organizations prevent sentinel events from occurring?

Healthcare facilities have been shown to benefit from standard, strategic approaches to patient safety, such as the Comprehensive Unit-Based Safety Program (CUSP) model’s safety framework. In keeping with that model, leadership can help improve patient outcomes and avoid significant adverse events by:

• Establishing a culture where harm is unacceptable.
• Encouraging clear communication and valuing honest reporting of errors and/or near-miss events.
• Utilizing all safety resources, including electronic safety stopgaps and clinical safety tools such as procedural timeouts, fall risk guides, and staff safety huddles.
• Engaging staff and facility leaders to spearhead initiatives that continue to investigate quality concerns and safety indicators, using collaborative efforts to guide better policies and safety strategies.

What is a sentinel event example in the hospital setting?

Patient falls are an unfortunately common sentinel event in hospital settings. Up to 20% of patient falls cause bone fracture, soft tissue injury, or head trauma, and most are preventable with strong fall-prevention strategies in place.

What is a sentinel event example in the long-term care setting?

Senior citizens are at high risk for depression. A resident dying by suicide while residing in a long-term care facility would count as a sentinel event for that organization.

What is a sentinel event example in the surgical setting?

One of the leading sentinel events in surgical settings is wrong surgery due to wrong site. For example, a patient having the wrong kidney removed.

How can sentinel event data help quality improvement efforts?

Proper follow-up after a sentinel event can improve future safety measures and may also reduce potential liability for the responsible organization. Using the data from a sentinel event also helps target reform initiatives to address the areas where breakdowns in safety were able to occur. It can help with tracking patterns in severe adverse events (like trends in the reasons behind patient falls) and align organizational culture with institutional values and goals.

Ready to Transform Your Approach to Patient Safety?

Now that you know how to answer, What is a sentinel event? you’re ready to prevent them in your organization. Evolve your current safety initiatives with IntelyCare’s wide array of expert-backed facility guides and resources to strengthen your safety culture and optimize outcomes.