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1. www.ojp.gov › pdffiles1 › nijPaving the Way: Lessons Learned in Sentinel Event Reviews

   www.ojp.gov › pdffiles1 › nij

   NCJ 249097. PAVING THE WAY: LESSONS LEARNED IN SENTINEL EVENT REVIEWS. When bad things happen in a complex system, the cause is rarely a single act, event or slip-up. More often, bad outcomes are “sentinel events.”. A sentinel event is a negative outcome that: • Signals underlying weaknesses in a system or process.

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2. www.jointcommissionjournal.com › article › S1070Sentinel Events: Approaches to Error Reduction and Prevention

   www.jointcommissionjournal.com › article › S1070

   Each approach To order Sentinel Events: Evaluating Cause and Planning Improvement, or for more information, call the Joint Com- mission Customer Service Center at 630/792-5800. 01998 by the Joint Commission Accreditation of Healthcare Organizations VOLUME 24 NUMBER 4 is described in this chapter, along with information on the basic risk ...

3. www.jointcommission.org › resources › sentinel-eventSentinel Event Policy and Procedures - The Joint Commission

   www.jointcommission.org › resources › sentinel-event

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   A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). An event can also be considered sentinel event even if the ...

4. nij.ojp.gov › library › publicationsThe Basics of Sentinel Events Reviews - Interview with James ...

   nij.ojp.gov › library › publications

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   Jan 1, 2014 · Abstract. A sentinel event is a significant negative outcome that: 1) signals underlying weaknesses in the system or process; 2) is likely the result of compound errors; and 3) may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.

5. www.ojp.gov › pdffiles1 › nijMending Justice: Sentinel Event Reviews - Office of Justice ...

   www.ojp.gov › pdffiles1 › nij

   sentinel event warnings with the rise of unexpected infections acquired in hospitals and when “wrong patient” surgeries occurred. In aviation, sentinel event warnings are sounded each time an airplane crashes or a near miss occurs. In criminal justice, a sentinel event could be similarly easy to recognize: the exoneration of an innocent person;

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6. www.ncbi.nlm.nih.gov › books › NBK564388Sentinel Event - StatPearls - NCBI Bookshelf

   www.ncbi.nlm.nih.gov › books › NBK564388

   Mar 29, 2023 · The Joint Commission defines a sentinel event as a patient safety event that results in death, permanent harm, or severe temporary harm. Sentinel events are debilitating to both patients and health care providers involved in the event. The term sentinel refers to a system issue that may result in similar events in the future. The National Quality Forum defined the term serious reportable ...

7. People also ask

   What is a sentinel event?

   • A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).

   Sentinel Event Policy and Procedures | The Joint Commission

   www.jointcommission.org/resources/sentinel-event/sentinel-event-policy-and-procedures/

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   Can sentinel event review be brought to the criminal justice system?

   • In bringing sentinel event review to the criminal justice system, we will, of course, need to forge our own specific process. The adversarial nature of our criminal justice system will make the process of developing a viable all-stakeholder, nonblaming, forward-looking sentinel event review process difficult.

   Mending Justice: Sentinel Event Reviews - Office of Justice Programs

   www.ojp.gov/pdffiles1/nij/247141.pdf

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   Can sentinel events improve criminal justice system legitimacy?

   • Enhancing organizational learning and sense-making in criminal justice through systematic reviews of sentinel events can go a long way to addressing systemic failure and improving justice system legitimacy. To do less returns us all to Indostan.

   Mending Justice: Sentinel Event Reviews - Office of Justice Programs

   www.ojp.gov/pdffiles1/nij/247141.pdf

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   How can the Joint Commission help with a sentinel event review?

   • The Joint Commission can provide support and expertise during the review of a sentinel event. The opportunity to collaborate with a patient safety expert in The Joint Commission’s Sentinel Event Unit of the Office of Quality and Patient Safety. Reporting raises the level of transparency in the organization and promotes a culture of safety.

   Sentinel Event Policy and Procedures | The Joint Commission

   www.jointcommission.org/resources/sentinel-event/sentinel-event-policy-and-procedures/

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   What is a sentinel event review?

   • Medical professionals use sentinel event reviews to examine unexpected patient deaths, medication errors, wrong-patient surgeries, “near misses” and similar incidents to account for their root causes. These reviews focus on reducing future risk, not on fixing blame for past mistakes. They look over the horizon to intercept preventable harms.

   Mending Justice: Sentinel Event Reviews - Office of Justice Programs

   www.ojp.gov/pdffiles1/nij/247141.pdf

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   Can a sentinel event be a non-blaming review?

   • If by studying a sentinel event — with all system stakeholders working together in a nonblaming review — we learn that the answer to any of these questions is “yes,” or even “yes, up to a point,” then we have uncovered something that we can address.

   Mending Justice: Sentinel Event Reviews - Office of Justice Programs

   www.ojp.gov/pdffiles1/nij/247141.pdf

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8. onlinelibrary.wiley.com › doi › fullApplying sentinel event reviews to policing - Hollway - 2019 ...

   onlinelibrary.wiley.com › doi › full

   jhollway@law.upenn.edu; University of Pennsylvania Law School. Correspondence. John F. Hollway, University of Pennsylvania Law School, 3501 Sansom Street, Philadelphia, PA 19104. Email: jhollway@law.upenn.edu. Search for more papers by this author