“A Sentinel Event is defined by The

“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.” Two sentinel events happened in a hospital in 1 month. A. 50 year old male in ICU passed away after suffering from Ventilator associated Pneumonia. Patient was vented after surgical removal of right lung lobe. It was post op day #9. B. 45 year old female passed away from overdose of patient controlled analgesic (PCA). Patient was placed on PCA after laparoscopic bowel resection. It was post op day #3. How would you prevent any future such sentinel events for A and B?

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