What it means
A term from The Joint Commission for the most serious kind of patient safety event, one not caused by the client's illness itself. Examples include surgery on the wrong site or wrong client, a fall that causes serious injury, a client's suicide in a hospital, and a major medication error. A sentinel event calls for an immediate investigation, called a root cause analysis, to find out why it happened and how to stop it happening again.
For the nurse
Report any serious event at once through the facility's reporting system, look after the client first, and describe the facts in an incident report. The purpose is to fix the system, not to blame one person.
At a glance
| Also written | sentinel events |
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Related terms
quality assurance
An organized way of checking that care meets set standards and of fixing problems when it does not.
near miss
An error or unsafe situation that was caught before it reached the client, so no harm was done.
incident report
A written record of an unexpected event in a health care setting that caused or could have caused harm.