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– JCAHO Policy –
Medical Errors and Patient Safety


JCAHO policy regarding definitions of sentinel events is very lax and is designed to permit participating facilities to develop their own standards for the adverse events that they monitor as sentinel events. In addition, JCAHO maintains a list of Reviewable Sentinel Events that are subject to review by the Joint Commission under the Sentinel Event Policy. Hence, at a minimum, participating facilities must report these ‘reviewable sentinel events.’

JCAHO defines a sentinel event as:

"an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.

Such events are called "sentinel" because they signal the need for immediate investigation and response."

JCAHO encourages a organization-specific definition list of sentinel events. JCAHO's policy standard for definitions of sentinel events is reproduced below from JCAHO's webpage.

III. Standards relating to Sentinel Events
Organization-specific Definition of Sentinel Event

The new Leadership standard requires each accredited organization to define “sentinel event” for its own purposes in establishing mechanisms to identify, report, and manage these events.

While this definition must be consistent with the general definition of sentinel event as published by the Joint Commission, accredited organizations have some latitude in setting more specific parameters to define “unexpected,” “serious,” and “the risk thereof.”

At a minimum, an organization's definition must include those events that are subject to review under the Sentinel Event Policy as defined in Section IV of this document [JCAHO website].

This web page is adapted directly from JCAHO's
Sentinel Events Policies and Procedures


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