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Sentinel Event Policy

The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help health care organizations that experience serious adverse events improve safety and learn from those sentinel events.

Careful investigation and analysis of Patient Safety Events (events not primarily related to the natural course of the patient’s illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm. The Sentinel Event Policy explains how Joint Commission International partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.

A sentinel event is a patient safety event that reaches a patient and results in any of the following:

  • Death
  • Permanent harm
  • Severe temporary harm and intervention required to sustain life

An event can also be considered sentinel event even if the outcome was not death, permanent harm, severe temporary harm, and intervention required to sustain life. Such events are called "sentinel" because they signal the need for immediate investigation and response.

Examples of events that are considered a sentinel event that require a review, include but are not limited to:

  • death that is unrelated to the natural course of the patient’s illness or underlying condition
  • death of a full-term infant
  • suicide
  • major permanent loss of function unrelated to the patient’s natural course of illness or underlying condition
  • wrong-site, wrong-procedure, wrong-patient surgery
  • transmission of a chronic or fatal disease or illness because of infusing blood or blood products or transplanting contaminated organs or tissues
  • infant abduction or an infant sent home with the wrong parents
  • rape, workplace violence such as assault (leading to death or permanent loss of function); or homicide (willful killing) of a patient, staff member, practitioner, medical student, trainee, visitor, or vendor while on hospital property.

Each accredited organization is strongly encouraged, but not required, to report sentinel events to The Joint Commission. Organizations benefit from self-reporting in the following ways:

  • JCI can provide support and expertise during the review of a sentinel event
  • The opportunity to collaborate with a patient safety expert at JCI
  • Reporting raises the level of transparency in the organization and promotes a culture of safety
  • Reporting conveys the health care organization’s message to the public that it is doing everything possible, proactively, to prevent similar patient safety events in the future

If an organization wishes to self-report an event that is subject to review by JCI Accreditation, the organization can submit the report to JCI at .