Sentinel event policy expanded beyond patients.

The Joint Commission defines 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.” Since its inception in 1996, The Joint Commission’s Sentinel Event Policy has focused on unexpected death or injury only when a patient, resident, or individual receiving care, treatment, or services is the victim. However, The Joint Commission recently expanded its policy to include certain harm events to staff, visitors, or vendors that occur while they are on the premises of the health care organization. The expansion is effective July 1, 2013. The subset of reviewable sentinel events includes any occurrence that has resulted in an unanticipated death or major permanent loss of function not related to the natural course of the individual’s illness or underlying condition. Examples of these events include a fall resulting in major permanent loss of function or a medication error that results in death. Events reviewable under the Sentinel Event Policy also include the defined subset of occurrences (even when they do not result in serious injury or death) in the box on page 3. The additional, recently approved language is underlined.