5 Steps to Handling a Sentinel Event From The Joint Commission

The Joint Commission offers free informational podcasts in a series called “Take 5 With The Joint Commission.”
“Take 5 With the Joint Commission: What to do when a sentinel event occurs” features pointers from Patricia McColl, RN, a patient safety specialist at The Joint Commission’s office of quality monitoring and patient safety, on what to do when a sentinel event occurs in your organization.

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A sentinel event, according to The Joint Commission, is “an unexpected occurrence involving death or serious physical or psychological injury or the risk therof.”

1. Secure the situation — ensure the immediate safety and wellbeing of any directly involved patients and staff.

2. Preserve and sequester anything that might be helpful in analysis process — this may include equipment, medication and more. Many organizations take photos of the scene of the sentinel event to aid in downstream analysis.

3. Disclose situationally relevant information to the patient or his or her designated caregiver as soon as possible.

4. Provide support for patients, family and staff — events have many victims, so a comprehensive support system of services to help them work through the aftermath of a sentinel event is essential.

5. Follow The Joint Commission’s reporting and root-cause analysis requirements, detailed in the organization’s accreditation manual.


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