Sentinel Event

The ultimate purpose of The Joint Commission’s accreditation process is to enhance quality of care and patient safety. Each requirement or standard, the survey process, the Sentinel Event Policy, and other Joint Commission initiatives are designed to help organizations reduce variation, reduce risk, and improve quality. Health care organizations should have an integrated approach to patient safety so that high levels of safe patient care can be provided for every patient in every care setting and service.

The Sentinel Event Policy explains how The Joint Commission partners with health care organizations that have experienced a serious patient safety event to protect the patient, improve systems, and prevent further harm.

The RCA2: Improving Root Cause Analyses and Actions to Prevent Harm describes methodologies and techniques that an organization or individuals can credibly and effectively use to prioritize the events, hazards, and vulnerabilities in their systems to understand what and why the event occurred, and how to prevent future events.