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The sentinel event data represents aggregate data from comprehensive systematic analysis (typically a root cause analysis) received by the Joint Commission Office of Quality and Patient Safety from January 1, 2023 through December 31, 2023.
29 Μαρ 2023 · Examples of sentinel events from the Joint Commission include the following: Suicide during treatment or within 72 hours of discharge. Unanticipated death during the care of an infant. Abduction while receiving care. Discharge of an infant to the wrong family.
sentinel event, or a cluster of less serious incidents or near misses occurs, organizations must develop an understanding of the contributing factors and the interrelationship of those factors.
6 Σεπ 2023 · The Joint Commission’s Sentinel Event Policy has the following four goals: To positively impact care, treatment, and services by helping health care organiza-tions identify opportunities to change their culture, systems, and processes to prevent unintended harm.
Sentinel Events: Evaluating Cause and Planning Improvement, a new book from the Joint Commission, describes the types of errors and sentinel events that have been reported in health care organizations, how organizations can respond to these events, how sentinel events are investigated through root cause analysis, and the Joint Commission's polic...
The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.
This article provides a rationale for RCA and the basic steps in a nonmedical RCA investigation. The article then describes a more detailed, 9-step, RCA approach for investigating sentinel events and illustrates the technique with a nuclear medicine example. Key Words: root cause analysis; sentinel event; quality.
