In 1996, the Joint Commission (TJC) adopted a formal policy regarding serious adverse patient events, known as sentinel events. The purpose of this sentinel event policy was to help hospitals experiencing such events improve patient safety. TJC defines a sentinel event as a “patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches the patient and results in any of the following: 1) death; 2) permanent harm; or 3) severe temporary harm.” TJC also lists a number of other conditions that are sentinel (Table) because they require immediate investigation and response by the hospital, and these investigations and responses are subject to review by TJC for appropriateness.

TJC considers sentinel events as patient safety events that result in patient harm. However, not all sentinel events occur because of a medical error and not all harm that results from medical...

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