What is the JCAHO definition of a sentinel event?
According to JCAHO, 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. Why are there gaps in the numbering of the National Patient Safety Goals? Gaps in numbering indicate a goal is either not applicable to the program under consideration or has been “retired.” Allowing gaps in the numbering of goals instead of renumbering them when one is retired or not applicable assures the goal always has the same number, and thus can be tracked more easily.
