Sentinel Events in Healthcare: Definition, Examples & Prevention

Definition

A sentinel event is an unexpected occurrence involving death, serious physical/psychological injury, or risk thereof. "Risk thereof" includes near-misses of serious harm.

Key Characteristics

• Typically result from system failures, not individual errors
• Occur in any healthcare setting
• Require reporting to state/federal agencies
• Trigger root cause analysis

Examples

• Unanticipated death
• Serious injury (fall, medication error)
• Wrong-site surgery
• Patient abduction/elopement
• Fire or disaster

Required Organizational Response

• Risk assessment and management
• Staff education and training
• Quality improvement programs
• Incident reporting and investigation systems

These policies aim to prevent recurrence and improve patient safety culture.