1. SENTINEL EVENTS
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12040141014 DEEVYA GAIKWAD
12040141017 AFSHEEN IRANI
12040141019 KIRAN KAUSHIK DASH
12040141020 KIRTI CHOUKIKAR
12040141021 RASHI THAPER
12040141022 STUTI SANGADA

2. SENTINEL EVENTS
 A Sentinel Event is defined by The Joint Commission (TJC) as any
unanticipated event in a healthcare setting resulting in death or serious
physical or psychological injury to a patient or patients, not related to the
natural course of the patient's illness.
 Sentinel events specifically include loss of a limb or gross motor
function, and any event for which a recurrence would carry a risk of a
serious adverse outcome. Sentinel events are identified under TJC
accreditation policies to help aid in root cause analysis and to assist in
development of preventative measures.
 The Joint Commission tracks events in a database to ensure events are
adequately analysed and undesirable trends or decreases in performance are
caught early and mitigated.

3. Sentinel events include "unexpected occurrences
involving death or serious physical or psychological
injury, or the risk thereof" and all of the
following, even if the outcome was not death or
major permanent loss of function:
 Infant abduction, or discharge to the wrong
family.
 Unexpected death of a full-term infant.
 Severe neonatal jaundice (bilirubin over 30
milligrams/deciliter).
 Surgery on the wrong individual or wrong body
part.
 Instrument or object left in a patient after surgery
or another procedure.
 Rape in a continuous care setting.
 Suicide in a continuous care setting, or within 72
hours of discharge.
 Hemolytic transfusion reaction due to blood
group incompatibilities.
 Radiation therapy to the wrong body region or
25% above the planned dose.

4. Event types- NABH
 Surgical events
( wrong body part/ patient/ procedure, retained instrument, death during the
procedure, anesthesia related events)
 Device or Product events
(contaminated drugs and device, unintended use, breakdown or failure)
 Patient protection events
(infant discharge, elopement, suicide, attempted suicide, self-harm, intentional
injury, nosocomial infection, medical gas )
 Environmental events
( burn, slip, trip, fall, electric shock, use of restrains and bed rails)
 Care management events
(hemolytic reaction, maternal death, medication errors, delay in response)
 Criminal events
(impersonation, abduction, sexual assault, physical assault on the grounds of
healthcare facility)

5. DIFFERENCE BETWEEN MEDICAL
ERROR & SENTINEL EVENT
MEDICAL ERROR
 44,000 AND 98,000 AMERICANS DIE EACH YEAR
 COMMON MEDICAL ERRORS
 INCORRECT ADMINISTRATION OF
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MEDICATION
 DOSAGE OR ROUTE OF
ADMINISTRATION
 FAILURE TO PRESCRIBE OR
ADMINISTER CORRECT DRUG
 USE OF OUTDATED DRUGS
 FAILURE TO OBSERVE CORRECT
TIME
 LACK AWARENESS OF ADVERSE
EFFECTS.
 HARD TO READ HANDWRITTEN
ORDERS
 DIFFERENT DRUGS
 DRUG ALLERGIES
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SENTINEL EVENT:
DEATH
PHYSICAL/PHSYCHOLOGICAL INJURY OR RISK
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LOSS OF LIMB OR FUNCTION
SUICIDE
RAPE
INFANT DEATH
INFANT DISCHARGED TO WRONG PARENTS
SURGERY ON WRONG PATIENT, OR BODY PART
INCORRECTLY MATCHED BLOOD TRANSFUSION
1,900 SENTINEL EVENTS REVIEWED BY THE
JOINT COMMISSION SINCE JANUARY 1995
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PATIENT SUICIDE ACCOUNTED FOR 16.5%
OF THE ERRORS
OPERATIVE/POST-OPERATIVE
COMPLICATION – 12.3%
WRONG-SITE SURGERY – 11.7
MEDICATION ERROR – 11.5

6. SENTINEL EVENT POLICY
To have a positive impact in improving patient care, treatment, and
services and preventing sentinel events.
To focus the attention of a disease-specific care program that has
experienced a sentinel event.
Understanding contributed factors
to an event (such as underlying
causes, latent conditions, and active failures in defense systems or
organizational cultures).
Disease-specific care program’s systems, culture, and processes to
reduce the probability of such an event in the future.
To increase the general knowledge about sentinel events, their
contributing factors, and strategies for prevention.
To maintain the confidence of the public and certified programs in the
certification process.

7. EXPECTATIONS FOR ORGANIZATIONS
REPORTING:
ROOT CAUSE ANALYSIS
• PROCESS TO IDENTIFY BASIC OR CAUSAL FACTORS OF
SENTINEL EVENTS CURRENT OR IN FUTURE
ACTION PLAN
• PLAN TO IDENTIFY STRATEGIES TO IMPLEMENT REDUCED
RISK OF SENTINEL EVENTS
SURVEY PROCESS
• EVALUATE THE FACILITIES COMPLIANCE WITH APPLICABLE
STANDARDS
• SCORE PERFORMANCE

8. Sentinel Event is Identified:
Inform the
CEO
Sentinel
event
identified
Reported
to the Joint
Commissio
n
Review
Process for
responding
to Sentinel
event
Interview
Leaders
Root Cause
Analysis

9. • IN SUMMARY
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SENTINEL EVENT:
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UNEXPECTED
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DEATH
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LOSS OF LIMB OR FUNCTION
SUICIDE
RAPE
INFANT DEATH
INFANT DISCHARGED TO WRONG
PARENTS
SURGERY ON WRONG PATIENT, OR
BODY PART
INCORRECTLY MATCHED BLOOD
TRANSFUSION
POLICY:
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IMPROVING
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PATIENT CARE
TREATMENT
SERVICES
PREVENTING SENTINEL EVENTS
FOCUS ON DISEASE SPECIFIC CARE
INCREASE KNOWLEDGE
CLASSIFY AND RESPOND TO SENTINEL
EVENT
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PHYSICAL/PHSYCHOLOGICAL INJURY
OR RISK
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REPORTING:
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ROOT CAUSE ANALYSIS
ACTION PLAN
IMPLEMENT IMPROVEMENTS
MEDICAL ERROR
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INCORRECT ADMINISTRATION OF
MEDICATION
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DOSAGE OR ROUTE OF
ADMINISTRATION
FAILURE TO PRESCRIBE OR
ADMINISTER CORRECT DRUG
USE OF OUTDATED DRUGS
FAILURE TO OBSERVE CORRECT TIME
LACK AWARENESS OF ADVERSE
EFFECTS.
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HARD TO READ HANDWRITTEN
ORDERS
DIFFERENT DRUGS
DRUG ALLERGIES