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A Sentinel Event is defined by The Joint Commission (TJC) as any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness. Sentinel events specifically include loss of a limb or gross motor function, and any event for which a recurrence would carry a risk of a serious adverse outcome. Sentinel events are identified under TJC accreditation policies to help aid in root cause analysis and to assist in development of preventative measures. The Joint Commission tracks events in a database to ensure events are adequately analyzed and undesirable trends or decreases in performance are caught early and mitigated. ==Specific events requiring review== Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof" and all of the following, even if the outcome was not death or major permanent loss of function: * Infant abduction, or discharge to the wrong family. * Unexpected death of a full-term infant. * Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter). * Surgery on the wrong individual or wrong body part. * Instrument or object left in a patient after surgery or another procedure. * Rape in an acute-care setting. * Suicide in an acute-care setting, or within 72 hours of discharge. * Hemolytic transfusion reaction due to blood group incompatibilities. 〔A fatal tranfusion reaction must be reported within 7 days.〕 * Radiation therapy to the wrong body region or 25% above the planned dose. In additional to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis. 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「sentinel event」の詳細全文を読む スポンサード リンク
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