What is a sentinel event, and how should it be handled?

What is a sentinel event, and how should it be handled?

• A. A near-miss that could have caused harm if not intercepted; reported for learning.
• B. A patient safety event resulting in death or serious injury; reported immediately, investigated, and corrective actions documented.
• C. An anticipated adverse event that was prevented by luck; logged privately.
• D. An event that caused no harm and requires no investigation.

Answer: (B)

A sentinel event is a patient safety event that results in death or serious injury, or places the patient at risk for such harm. Because this signals a major flaw in the safety system, it must be reported immediately, investigated (usually with a root cause analysis) to uncover underlying causes, and the corrective actions documented and implemented to prevent recurrence. This process aims to improve system-wide safety rather than assign blame, turning a serious incident into a learning opportunity for safer care.

Other scenarios describe events like near-misses (which could have caused harm but didn’t) or luck-based prevention, or situations where no harm occurred. Those don’t meet the criteria for a sentinel event and don’t trigger the same urgent, formal investigation and documentation path.