sentinel event love


from Wiktionary, Creative Commons Attribution/Share-Alike License

  • n. As defined by the Joint Commission on Accreditation of Healthcare Organizations, any unanticipated or unusual event in a medical setting which results in death or serious physical injury to a person or persons, specifically including limb loss or gross motor function.


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  • Preventable adverse events — injuries due to medical errors — are a major cause of death among Americans. Although some progress has been made in reducing certain types of adverse events, overall rates of errors remain extremely high. Failures of communication, including miscommunication during handoffs of patient care from one resident to another, are a leading cause of errors; such miscommunications contribute to two of every three “sentinel events,” the most serious events reported to the Joint Commission. The omission of critical information and the transfer of erroneous information during handoffs are common. As resident work hours have been reduced, handoffs between residents have increased in frequency.

    Amy J. Starmer et al.l, "Changes in Medical Errors after Implementation of a Handoff Program, New England Journal of Medicine, vol. 371, pp. 1803-12 (2014) (footnotes omitted).

    March 23, 2016