Sentinel Events, Serious Reportable Events, and Root Cause Analysis

The term sentinel event was defined by the Joint Commission to describe unexpected occurrences that resulted in death or serious physical or psychological injury to a patient. The term sentinel is meant to imply that the event may be a warning signal for ongoing problems in the content or process of care that may well lead to additional events. Institutions differ on the definition, internal reporting, and investigation of sentinel events and reporting of these events to the Joint Commission is voluntary. An ophthalmic example of a sentinel event would be a wrong intraocular lens (IOL).¹