"Sentinel event", it’s a term that immediately signals gravity in the world of healthcare. These events are not just serious; they’re often life-altering, sometimes life-ending, and always require a critical analysis and response.

But outside of clinical circles or root cause review committees, many still don’t fully understand what sentinel events are, what they look like, or how to evaluate whether a healthcare agency did all it could to prevent them. Whether you're an attorney reviewing a medical case, a consultant assessing liability, or a healthcare professional trying to understand your responsibility this insight is for you.

Let’s answer the question first.

What Is a Sentinel Event?

According to The Joint Commission, a sentinel event is defined as:

“A patient safety event that results in death, permanent harm, or severe temporary harm and intervention required to sustain life.”

It is an unexpected occurrence in a health care setting that is NOT related to the present illness and it results in harm or death.

These are not expected complications or routine risks, they're red flags that something went seriously wrong, often in a preventable way.

Sentinel events are not always due to negligence, but they do trigger an obligation: immediate investigation, system review, and corrective action.

Examples of Sentinel Events

Some of the most common sentinel events include:

• Wrong-site surgery
  Operating on the wrong limb, organ, or patient. We have all heard these horror stories. There is a failure to mark the correct site and something horrible happens.

• Unintended retention of a foreign object after surgery
  Sponges, instruments, or tools left inside the body post-op. These events can lead to pain, internal damage, and sepsis.

• Patient suicide while under care
  Particularly in inpatient psychiatric or med-surg units where suicide precautions were warranted. An overburdened system is leading to an increase in patient suicide.

• Delay in treatment leading to death or permanent harm
  Often tied to diagnostic failure, poor triage, or communication breakdown. More recently there has been a trend demonstrating a lack of verbal communication between providers and caregivers.

• Medication errors
  Especially those involving high-alert medications or incorrect administration routes/doses. Override capability, look alike sound alike drugs, a lack of following the rights of medication administration at all levels in the process.

• Maternal death related to labor and delivery
  Particularly with hemorrhage, hypertensive disorders, or anesthesia complications.

• Infant abduction or discharge to the wrong family
  Though rare, these events are classified due to their severity and system failures.

• Injury or death due to patient elopement
  Vulnerable patients (e.g., dementia, psychiatric) leaving undetected and being harmed. Often seen in assisted living or long-term care environments.

These are never minor issues. And even when outcomes are unintentional, accountability still matters.

What to Look for in Prevention (or the Lack of It)

When evaluating whether a healthcare agency took appropriate steps to prevent a sentinel event, here’s where to focus:

1. Pre-Existing Risk Assessments

• Was the organization actively identifying risks through proactive tools like Failure Mode and Effects Analysis (FMEA)?

• Did leadership have a culture of safety, or was it reactive?

• Did leadership have a culture of safe reporting or did it penalize staff for reporting?

2. Staff Training and Competency

• Were staff trained on relevant protocols, especially high-risk procedures?

• Are continuing education and competency assessments documented?

• Did the health care system promote external learning experiences that support current trends and standards for care and practice

3. Policy and Procedure Adherence

• Were the existing protocols followed?

• Were the existing protocols up to date?

• If a protocol wasn’t followed, was there a documented justification or noted deviation?

4. Communication Practices

• Were critical changes in patient status clearly documented and communicated?

• Were handoffs and transitions of care thorough, using standardized tools (e.g., SBAR, checklists)?

• Was follow-up to the communication documented. What happened? Was a chain of command reporting process activated? Were orders for care and treatment changed or updated?

5. System and Equipment Factors

• Was the equipment functioning properly?

• Were known malfunctions or workarounds ignored or normalized?

• Was an improperly functioning piece of equipment removed immediately from service and patient contact?

6. Immediate Response and Root Cause Analysis (RCA)

• Did the agency initiate an internal investigation? Who performed the RCA?

• Was an RCA conducted and documented?

• Did corrective action plans address systemic failure and not just individual blame?

7. Post-Event Transparency and Learning

• Was the event reported to accrediting bodies, if required?

• Did the organization share lessons learned to prevent recurrence?

• How did the organization share the lessons learned and what was the response?

If these areas reveal gaps, missed warnings, or superficial responses, it may suggest the organization failed to do everything it could have.

Why It Matters in Legal and Clinical Settings

In legal cases, understanding sentinel events is critical for determining if a breach in the standard of care occurred. But it goes beyond litigation, sentinel events are indicators of organizational health and how safety is truly prioritized in practice.

As a Legal Nurse Consultant, I work with attorneys and healthcare systems to investigate these events, provide expert review, and identify the real story behind what went wrong and why.

Sentinel events are stories of patients, families, and professionals impacted by systems that did not anticipate and plan for unexpected outcomes or hold to standards of care and practice. When properly investigated and addressed, these events become opportunities to correct course and improve outcomes. When ignored or minimized, they become recurring issues for safety and compliance to standards creating significant risk.

Need help reviewing a sentinel event case or building prevention strategies?
📨 Email: [email protected]
🌐 Website: www.upvisionconsulting.com
🔗 Connect: Follow for more insights on clinical risk, legal strategy, and healthcare improvement.

Let’s Continue the Conversation. Register for the ARC 2025 in Detroit Michigan https://attorneysconference.com/

References

Al Thubaity, Daifallah & Mahdy, Abeer. (2023). Perception of Health Teams on the Implementation of Strategies to Decrease Nursing Errors and Enhance Patient Safety. Journal of Multidisciplinary Healthcare. 16. 693-706. 10.2147/JMDH.S401966.

Dhingra, J., Farrell, M. B., & Halkar, R. K. (2022). Root cause analysis in nuclear medicine for sentinel events. Journal of Nuclear Medicine Technology, 50(4), 301–308. https://doi.org/10.2967/jnmt.122.264660

Kellogg KM, Hettinger Z, Shah M, Wears RL, Sellers CR, Squires M, Fairbanks RJ. Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf. 2017 May;26(5):381-387. doi: 10.1136/bmjqs-2016-005991. Epub 2016 Dec 9. PMID: 27940638.

Peerally, M. F., Carr, S., Waring, J., & Dixon-Woods, M. (2019). The problem with root cause analysis. International Journal for Quality in Health Care, 31(2), 110–116. https://doi.org/10.1093/intqhc/mzy157

Singh G, Patel RH, Vaqar S, et al. Root Cause Analysis and Medical Error Prevention. [Updated 2024 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570638/