SENTINEL EVENTS AND ROOT CAUSE ANALYSIS
Information regarding sentinel events is available through the Joint Commission
website www.jointcommission.org or call their sentinel event hotline: 630-792-3700.
SENTINEL EVENTS DEFINITION
The following criteria define the subject of sentinel events that are reviewable by Joint
Commission on a voluntary basis under the Sentinel Event Policy. Only those sentinel
events that affect recipients of care (patients, clients, and residents), and that meet the
following criteria, fall into this category. The Sentinel Event Policy applies only to
events that meet the following criteria:
The event has resulted in an unanticipated death or a major permanent loss of
function, not related to the natural course of the patient’s illness or underlying
1. A distinction is made between an adverse outcome that is related to the natural
course of the patient’s illness or underlying condition (not reportable) and a
death or major permanent loss of function that is associated with the treatment
or lack of treatment, of that condition (voluntary reportable).
2. “Major permanent loss of function” means sensory, motor, physiologic, or
intellectual impairment not present on admission requiring continued
treatment or lifestyle change. When “permanent loss of function” cannot be
immediately determined, reporting is not expected until either the patient is
discharged with continued major loss of function, or two weeks have elapsed
with persistent major loss of function, whichever occurs first.
The event is one of the following (even if the outcome was not death or major
permanent loss of function):
1. Suicide of the patient receiving care, treatment and services in a staffed
around-the-clock care setting or within 72 hours of discharge.
2. Unanticipated death of a full-term infant.
3. Abduction of any patient receiving care, treatment and services.
4. Discharge of patient to the wrong family.
6. Hemolytic transfusion reaction involving administration of blood or blood
products having major blood group incompatibilities.
7. Surgery on the wrong patient or body part.
8. Unintended retention of a foreign object in a patient after surgery or other
9. Severe neonatal hyperbilirubinemia (bilirubin > 30 milligrams/deciliter)
10. Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or
any delivery of radiotherapy to the wrong body regions or >25% above the
planned radiotherapy dose.
IDENTIFYING SENTINEL EVENTS
Joint Commission requires each accredited organization to define sentinel event for its
own purposes in developing tools for identifying, evaluating and managing such events.
The organization’s definition must at least be consistent with the Joint Commission’s
definition as defined below.
As defined by the Joint Commission, a sentinel event is:
An unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof. Serious injury specifically includes
loss of limb or function. The phrase “or the risk thereof” includes any process
variation for which a recurrence would carry a significant chance of a serious
Such events are called “sentinel” because they signal the need for immediate
investigation and response.
The terms “sentinel event” and “medical error” are not synonymous; not all
sentinel events occur because of an error and not all errors result in sentinel
An organization may define sentinel event in a broader sense in efforts to include
incidents in which a process or system improvement may be identified and evaluated.
Some examples would be to include those incidents that qualify as a Code 15 pursuant to
EVALUATING SENTINEL EVENTS
Once you have determined that a sentinel event has occurred in your organization, the
next step is evaluating the incident using a root cause analysis. As defined by the Joint
Commission, the root cause analysis is:
A process for identifying the basic or causal factor(s) that underlie variation in
performance, including the occurrence or possible occurrence of a sentinel event.
Essentially, a root cause analysis is an objective tool that focuses on process and system
issues as opposed to individual performance. The root cause analysis should be
conducted as soon after the event as possible. The facilitator must keep in mind that it is
easy to deviate from this focus and get into the strategies for defense and peer review.
For this tool to be effective, the focus must remain on process and system issues.
The following tips are provided by the Joint Commission to help conduct a root cause
Assign a team to assess the sentinel event. This team should include staff at
all levels closest to the issue(s) and those with decision-making authority.
Communicate the team’s progress and finding to senior leadership-keep them
Create a high-level work plan that includes target dates for accomplishing
specific objectives to provide a tool to guide and measure your progress.
Brainstorm all possible or potential contributing factors. Focus on processes,
not people, until all possible questions and factors have been exhausted.
Sort and analyze the list of contributing factors. Constructing a cause-and-
effect diagram can be very helpful in this sorting process.
Search for the common causes in systems to find special causes in a process.
Make intermediate changes as appropriate and necessary.
Be thorough. Do not stop the analysis before identifying the root causes and
taking corrective action.
The Joint Commission provides a recommended framework for a root cause analysis on
its website. Although the format for a root cause analysis may differ from organization to
organization, it should at least fulfill the criteria provided below before it will be
considered acceptable by the Joint Commission.
Focuses primarily on systems and processes, not individual performance;
Progresses from special causes in clinical process to common causes in
Repeatedly digs deeper by asking “Why?”; then, when answered, “Why?”
again, and so on;
Identifies changes which could be made in systems and processes- either
through redesign or development of new systems or processes- that would
reduce the risk of such events occurring in the future; and
Is thorough and credible including the identification of potential
improvements, identified by the leadership of the organization and those
individuals most closely involved. Consideration should be given to any
THE ACTION PLAN
Once your analysis is complete and you have identified the causal factor(s) that underlie
variation in performance, the next step is to develop an action plan. The action plan is
designed to identify all strategies the organization should implement to aid in the
reduction of future sentinel events. To further eliminate any possibilities of a future
sentinel event occurring the action plan should concentrate on responsibility for
implementation, oversight, pilot testing as appropriate, time lines, and strategies for
measuring the effectiveness of the actions. Thoroughness and credibility are two very
important aspects when constructing an acceptable action plan. According to The Joint
Commission, the action plan should be completed with in 45 days of the events
occurrence and in order for the plan to be considered acceptable the following is
The action plan identifies changes that can be implemented to reduce risk, or
formulates a rationale for not undertaking such changes; and
Where improvement actions are planned, it identifies who is responsible for
implementation, when the action plan will be implemented - - including any
pilot testing, and how the effectiveness of the actions will be evaluated.
REPORTING OF SENTINEL EVENTS AND ROOT CAUSE ANALYSIS
All sentinel events and their root cause analysis should be reported internally through
your organization’s appropriate committees, with documentation in the committee
Organizations are also encouraged, but not required, to report any reviewable sentinel
event to the Joint Commission.
The Joint Commission may become aware of a sentinel event through means other than
self-reporting, such as communication from a patient, family member, employee,
surveyor during an on-site survey, or the media. A response to the event may be required,
in accordance with Joint Commission Standards.