Manage all identified cases of unanticipated death or major permanent loss of function associated with health care associated infection as sentinel events.

What It Means
When infection is associated with an unexpected negative outcome, the event must be considered a sentinel event. A sentinel event is an unexpected occurrence or risk of occurrence that involves death or serious physical or psychological injury. Risk of occurrence means that, although no harm occurred this time, any recurrence would carry a significant chance of a serious negative outcome. Sentinel events require that a thorough analysis (called a "root cause analysis") of both the event and the infection be completed to determine the cause.

Why It Is Important
Joint Commission believes that managing these cases as sentinel events will provide additional information-not so much about the infection itself, but about managing patients at risk for infection who have acquired an infection. In this manner, the root cause analysis will contribute to reducing the risk of patient harm from health care-associated infection.

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