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Sentinel events are a subcategory of adverse events. A sentinel event is a patient safety event that is not primarily related to the natural course of the patient's illness or underlying condition, reaches the patient, and results in death, permanent harm, or severe temporary harm (TJC, January 2018). For example, imagine that the nurse administered a unit of packed red blood cells intended for Ms. Johnston to Ms. Johnsen. The results could be catastrophic, and the health care team would need to take immediate action to save Ms. Johnsen's life. After the immediate crisis is handled, sentinel events must be carefully investigated. Corrective action plans must be created to reduce risk and prevent harm for future patients.

TJC is an independent, not‐for‐profit group in the United States that provides accreditation for many hospitals and other health care organizations. TJC publishes a list of the most frequently occurring sentinel events, summarized in Table 4.1. The reporting of sentinel events is voluntary and represents only a small proportion of actual sentinel events.

Table 4.1 Five Most Frequent Sentinel Events, 2014 through 2017 (TJC, January 2018)

Event	Definition	Number of Reported Events
Unintended Retention of a Foreign Body	An unintended retention of a foreign body is defined as the retention of a foreign object in a patient after surgery or other procedure.	481
Wrong‐patient, wrong‐site, wrong‐procedure	A wrong‐patient procedure occurs when the procedure is performed on the incorrect patient. A wrong‐site procedure involves operating on the wrong side of a patient. A wrong procedure occurs when an incorrect procedure is performed on a patient.	409
Fall	A fall sentinel event is defined as an unplanned descent to the floor resulting in death, permanent harm, or severe temporary harm.	404
Suicide	A suicide sentinel event is defined as intentionally killing oneself in a healthcare setting.	361
Delay in treatment	A delay in treatment sentinel event is when a patient does not get any type of treatment (medication, lab test, etc.) that was ordered for them in the time frame in which it was supposed to be delivered, and the delay results in death, permanent harm, or severe temporary harm.	290
Total number of reported sentinel events	A subcategory of Adverse Events, a Sentinel Event is a patient safety event (not primarily related to the natural course of the patient's illness or underlying condition) that reaches a patient and results in any of the following: Death; Permanent harm; or Severe temporary harm.	3,326

Source: The Joint Commission (January 2018). Patient Safety Systems. Retrieved from https://www.jointcommission.org/assets/1/6/PS_chapter_HAP_2018.pdf.