Foundations of Patient Safety: Defining Sentinel Events, Never Events, and Serious Reportable Events

According to a report from the U.S. Department of Health and Human Services in 2022,  approximately 25% of patients may experience harm that is largely preventable during hospitalization (Joint Commission and National Quality Forum, 2026). In response, The Joint Commission (TJC) and the National Quality Forum (NQF) have been at the forefront, leading national efforts to address these issues, including the development of policy and measurement. This began with defining adverse events and creating a reporting framework. Driving meaningful change and improvement requires a systematic approach: adverse events must be clearly defined, identified by frontline staff, reported to leadership, thoroughly investigated, and followed by corrective actions to prevent recurrence.

This article describes the origins, purpose, and terms used to describe adverse events- sentinel events, never events, and serious reportable events. 

Sentinel Event

In 1996, TJC began work on defining adverse events by developing a Sentinel Event Policy. Sentinel events are defined as “a subcategory of adverse events. A sentinel event is a patient safety event, not primarily related to the natural course of a patient’s illness or underlying condition, that is clearly tied to a patient encounter, serious, and largely preventable.” (The Joint Commission, 2026, p. SE-2). 

The current list contains 31 events in the categories of procedural, product/device, patient protection, care provision, and workforce safety.  Many of these events are based on patient harm (death, severe or permanent harm) or any instance of an event occurring irrespective of the outcome (The Joint Commission, 2026). This is based on the premise that even near misses represent serious system vulnerabilities with potential patient harm and should be reported for these reasons.  For example, sentinel event (SE) 2, unintentionally retained items after surgery or an invasive procedure, is applicable regardless of the outcome. Within the maternal/neonatal area, 3 harm-associated events are defined: 

SE 25. Maternal patient harm associated with labor or delivery in a low-risk pregnancy

SE 26. Neonatal patient harm associated with labor or delivery in a low-risk pregnancy 

SE 27. Patient harm associated with the care of a neonate (The Joint Commission, 2026, p. SE-5) 

The Sentinel Event Policy and associated list is intended for use by healthcare organizations to drive investigation into root causes, learning, and improvement in patient outcomes. In addition, organizations are encouraged to voluntarily report these events to the TJC. 

Around the same time as this work was being done by the JC, similar efforts were underway by the NQF to raise awareness around preventable patient harm reflective of healthcare system gaps (Joint Commission and National Quality Forum, May 2026).  

Never Events and Serious Reportable Events

“Never event” essentially refers to adverse events that should never happen. It is a phrase created in 2001 by Kenneth Kizer, CEO of the National Quality Forum (NQF), that refers to blatant medical errors, such as the retention of foreign objects after surgical procedures. The original list of never events has evolved into what is now known as the Serious Reportable Event (SRE) list. It is used by many states for mandatory or voluntary reporting, to identify system problems, drive improvement efforts in patient safety, and inhibit event recurrence. (Joint Commission and National Quality Forum, May 2026). 

In 2023, TJC and the NQF came together to align these two parallel measurement systems- the SRE list and the JC Sentinel event list. The goal of this work was to aid in reducing healthcare organizations’ burden of reporting and allow more focus on improvement efforts.  Around this time, the NQF began updating the SRE list to be more patient-centered, reflective of the current healthcare arena, and to guide standardized reporting. In January 2027, TJC will adopt the updated NQF list into its revised Sentinel Events List, while also maintaining previous workplace safety sentinel events. 

Examples of serious reportable events- also Joint Commission Sentinel Events- include but are not limited to the following: 

• Unintentionally retained medical or surgical item after surgical or invasive procedures 

• Wrong-patient surgery or invasive procedure 

• Wrong-site surgery or invasive procedure 

• Wrong-procedure surgery/invasive procedure

• Falls associated with harm 

• Medication errors associated with harm

• Maternal or neonatal harm associated with labor or delivery in low-risk  pregnancies 

• Harm associated with the care of a neonate* (Joint Commission and National Quality Forum, May 2026). 

*newly added 

Case Example

This clinical case review presents a real example of a double event that meets criteria for a serious reportable event and sentinel event that affected a patient. 

A patient in the ICU was ordered a procedure to aspirate fluid from his left ankle. The surgical intern and second-year resident entered the patient’s room and acquired consent over the phone from the patient’s wife. A time-out was conducted with the bedside nurse, who questioned why the procedure was being done, as the patient had wounds on both feet and osteomyelitis in his left foot. At this point, one of the residents double checked the electronic medical record to ensure they had the correct patient, reporting this to the nurse and the other resident.

Despite the nurse’s continued concern, they moved forward. The procedure was conducted on the patient’s right ankle and shortly after a third resident entered the room, notifying the other residents that this was the wrong patient. The procedure was immediately discontinued, and the patient and family were informed that an error had occurred. There were no further complications resulting from this procedure (Bellini & Salcedo, 2024).

Reflection Questions:

• Where did the safety systems fail in this scenario? (e.g., breakdown in time-out verification, failure to empower the bedside nurse when clinical judgment conflicted with the plan)

• How could a leader empower a bedside nurse to halt a procedure more effectively when a discrepancy is identified?

References

Bellini, A., & Salcedo, E.S. (2023, September 27). A Double “Never Event”: Wrong Patient and Wrong Side. PSNet Patient Safety Network. Retrieved on 9/6/25 from https://psnet.ahrq.gov/web-mm/double-never-event-wrong-patient-and-wrong-side

Joint Commission and National Quality Forum (2026, May). Aligning Patient Safety Event Reporting: 2025 Updates to Sentinel Events and Serious Reportable Events. Washington, DC: NQF.  

The Joint Commission. (2026). 2027 sentinel event policy. 

National Quality Forum. (2024, April 4). NQF to Update and Harmonize Serious Adverse Event Reporting Criteria Essential to Protect Patients From Preventable Harm. Retrieved on 9/6/25 from https://www.qualityforum.org/en-us/news/nqf_to_update_and_harmonize_serious_adverse_event_reporting_criteria_essential_to_protect_patients

UC Davis PSNet Editorial Team (September 15, 2024). Never Events. Agency for Healthcare Research and Quality PSNet Patient Safety Network. Retrieved on 9/6/25 from https://psnet.ahrq.gov/primer/never-events

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About the Author

Jeanette Zocco, MSN, RNC-OB, C-EFM, C-ONQS, is a leader in perinatal quality and safety with 28 years of experience in obstetrics. She has served as a bedside nurse, charge nurse, clinical nurse leader, perinatal safety nurse, and quality improvement specialist. Currently, she is a perinatal patient safety program manager, supporting quality and safety work for a multi-hospital healthcare system. Jeanette is recognized for developing innovative perinatal quality and safety programs in collaboration with multidisciplinary teams.

💡If you enjoyed this article, check out her comprehensive study guide book, Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on Amazon!  Amazon_obneonatalstudyguide 

Copyright by Jeanette Zocco MSN RNC-OB, C-EFM, C-ONQS