Outcome such a “near miss” falls within the scope of the definition of anĪdhering to a sentinel event policy should not only reduce the Outcome but for which a recurrence carries a significant chance of a serious adverse Organisation, and a near miss is any process variation that did not affect an Unanticipated, undesirable, or potentially dangerous occurrence in a healthcare Such an event is called sentinel because it signals a need for an immediate Underlying condition or wrong-site, wrong-procedure, wrong-patient surgery. Of function unrelated to the natural course of the patient's illness or JCI defines a sentinel event as an unanticipated death or loss Of their own, as well as establishing a process to address a sentinel event (see Figure 1) as a baseline for compliance and develop a sentinel event policy Requiring that all JCI-accredited hospitals heed JCI's Sentinel Event Policy Undesirable events with varying degrees of serious outcomes. Joint Commission International (JCI) introduced the international healthcareĬommunity to the term sentinel event, which when combined with the alreadyįamiliar terms adverse event and near miss, describe the full range of With the release of the Joint Commission InternationalĪccreditation Standards for Hospitals, 3rd edition, US-based accreditation body By conducting intensive system analysis, revising processes found toĬause or contribute to these events, and monitoring the effectiveness of anyĬhanges, quality hospitals create a safer patient environment following an In a way that significantly reduces the risk of the event occurring in theįuture. Organisations from lesser ones is whether they respond to sentinel and adverse events Limited to lower quality organisations excellent healthcare organisations canĪnd do experience undesirable events. Which are called sentinel events, the less severe, adverse events-are not Too common in hospitals throughout the world. Reporting of sentinel events to The Joint Commission is a voluntary process, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.Preventable medical errors threaten patient safety and are all The remaining sentinel events were reported either by patients or their families, or employees of a healthcare organization. Most sentinel events (90%) were voluntarily self-reported to The Joint Commission by an accredited or certified healthcare organization. Of all the sentinel events, 20% were associated with patient death, 44% with severe temporary harm and 13% with unexpected additional care/extended stay. Most reported sentinel events occurred in a hospital (88%).
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