What it means
A team investigation that asks not only what happened and how, but why. It looks at processes, equipment, staffing, communication and policies rather than blaming one person, then sets changes to stop the same thing happening again. The Joint Commission expects hospitals to do one after a sentinel eventSEN-tih-nul ee-VENTAn unexpected event in health care that causes a client's death, permanent harm or severe temporary harm.Full entry .
For the nurse
Nurses take part by reporting errors and near misses promptly through the facility's reporting system and by describing honestly what happened. Speaking up is protected in a just culture.
Related terms
evidence-based practice
Care that combines the best research findings with clinical experience and the client's own wishes.
sentinel event
An unexpected event in health care that causes a client's death, permanent harm or severe temporary harm.