What is a sentinel event, and what is the manager's required response?

• A. A sentinel event is an unexpected occurrence resulting in death or serious injury; the manager must report it, initiate an immediate safety review, and perform a root cause analysis.
• B. A minor incident that does not affect patient safety.
• C. An event caused by patient factors, not system factors.
• D. An event that should be documented but not investigated.

Answer: (A)

Sentinel events are events that are unexpected and result in death or serious injury, or the risk of such harm, signaling a breakdown in safety systems. The manager’s required response is to report the event to the appropriate leaders and risk management, start an immediate safety review to address urgent patient protections, and conduct a root cause analysis to identify system weaknesses and develop actions that will prevent recurrence. The analysis focuses on underlying processes and systems rather than blaming individuals, aiming to strengthen safety culture and prevent future harm.

The other statements describe a minor incident, an event caused solely by patient factors, or only documenting without investigation, which do not meet the definition or the required response for sentinel events.