The Joint Commission's National Patient Safety Goals: implications for home care and hospice organizations.

*"A sentinel event is 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."