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Center for Professional Practice of Nursing

Center for Professional Practice of Nursing

Sentinel events

Leadership standards require that hospital leadership define, implement, and communicate a process for identifying and responding to sentinel events. You can be certain that surveyors will ask about your hospital's sentinel events policy during the JCAHO interview. Each nurse should be able to identify, report and respond to sentinel events according to hospital policy. Staff are expected to know that a sentinel event is an event that has resulted in:

An unanticipated death or major permanent loss of function not related to the natural course of the patient's illness or underlying condition. The following events are also considered sentinel events even if the outcome was not death or major permanent loss of function:

  • Suicide of a patient in a setting where the patient receives round-the-clock care (i.e. hospital, residential treatment center, crisis stabilization center)
  • Infant abduction or discharge to the wrong family
  • Rape
  • Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities
  • Surgery on the wrong patient or wrong body part

See UC Davis Health System Policy # 1440: Sentinel Events.