The hospital’s definition of a sentinel event includes a) through f) above and may include other events as
required by laws or regulations or viewed by the hospital as appropriate to add to its list of sentinel events. All
events that meet the definition of sentinel event must be assessed by performing a credible root cause analysis.
Accurate details of the event are essential to a credible root cause analysis, thus the root cause analysis needs to
be performed as soon after the event as possible. The analysis and action plan is completed within 45 days of the
event or becoming aware of the event. The goal of performing a root cause analysis is for the hospital to better
understand the origins of the event. When the root cause analysis reveals that systems improvements or other
actions can prevent or reduce the risk of such sentinel events recurring, the hospital redesigns the processes and
takes whatever other actions are appropriate to do so.
It is important to note that the terms sentinel event and medical error are not synonymous. Not all errors result in a
sentinel event, nor does a sentinel event occur only as a result of an error. Identifying an incident as a sentinel
event is not an indicator of legal liability. (Also see GLD.4.1, ME 2)