Learning from Serious Patient Safety Events

Jeanette Zocco
3 days ago
3 min read

A sentinel event, as defined by the Joint Commission (TJC), is a patient safety event resulting in death, permanent harm, or severe temporary harm. It must also be unrelated to any underlying condition or illness. TJC formalized a Sentinel Event Policy in 1996 to assist organizations in learning from these serious patient safety events and creating safer care environments. This includes conducting a comprehensive analysis, identifying any underlying causal factors, and developing a corrective action plan to prevent future recurrences. This review must occur within 45 days of the event or upon becoming aware of the event. The ultimate goal is to correct system vulnerabilities and prevent future patient harm. (The Joint Commission, Jan 2025)

Sentinel events may occur in any setting—acute care, outpatient, or long-term care—and are not always due to individual error, but they consistently reveal opportunities to strengthen safety systems.

Here are several examples that would qualify as a sentinel event, if they occurred in a Joint Commission-accredited organization:

Unanticipated death of a full-term infant
Any intrapartum maternal death
Severe maternal morbidity (leading to permanent or severe harm)
Wrong-site surgery
Retention of a foreign object
Wrong site or wrong patient surgery
Discharge of an infant to the wrong family
Fall resulting in injury (The Joint Commission, Jan 2025)

Clinical Example

In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.

An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.

In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. …the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal. (Kinnan,2006, paras 1-3)

Learning from Sentinel Events

TJC requires organizations to conduct a comprehensive analysis, such as a root cause analysis, focusing on systems-level vulnerabilities rather than individual care provider performance (The Joint Commission, Jan 2025). Reporting to TJC is encouraged but not required.

Sentinel events highlight potential vulnerabilities in communication, teamwork, human factors, and system design. They may provide critical learning opportunities to strengthen a culture of safety. Common contributing factors in obstetric sentinel events include inadequate escalation of concerns, lack of situational awareness, or unclear chain of command during emergencies.

Learning from sentinel events helps ensure that preventable harm is not repeated—and that every event drives improvement across the system.

Study Questions

1. Which of the following best defines a sentinel event according to The Joint Commission? A. Any event reported to risk management B. A patient safety event resulting in death, permanent harm, or severe temporary harm C. Any medication error that reaches the patient D. An adverse event caused by negligence

Answer: B Rationale: Sentinel events are defined by the outcome—death or major harm—not by fault or negligence. They serve as “signals” for immediate review and system learning.

2. Following identification of a sentinel event, what is the organization’s next required step? A. Notify CMS within 24 hours B. Report the event to The Joint Commission immediately C. Conduct a root cause analysis and develop an action plan D. Suspend all involved staff pending review

Answer: C Rationale: The Joint Commission requires healthcare organizations to perform a thorough systematic analysis, such as a root cause analysis, within 45 days to identify contributing factors and corrective actions. Reporting the event to The Joint Commission is voluntary; implementing safety improvements is mandatory.

Key takeaway: Sentinel events can create powerful catalysts for improvement. Every review offers a potential chance to strengthen teamwork, refine processes, and advance safety for patients and healthcare teams alike.

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