A sentinel event is an unanticipated occurrence that may involve
Death or major permanent loss of function unrelated to the patients’ illness or condition
May occur due to wrong-site, wrong procedure, wrong-patient surgery and
Signals a need for immediate investigation and response
Sentinel events may also be serious breaches in standards, processes, procedures, policies or care environment that causes harm, loss, or risk thereof.
Notification of sentinel events is outlined in the Risk Management Program. A suspected sentinel event is brought to the immediate attention of the QI Coordinator and to the Chief of the Department, who decide if a sentinel event has occurred. If it is determined that the event is a sentinel event, a specialized team is assigned to perform a Root Cause Analysis (RCA) and report findings to Medical Management and the Quality Improvement Counsel Committee which implements the recommendations of the RCA to prevent reoccurrence.