Sentinel Event Alert: The Essential Role of Leadership in Developing a Safety Culture

Leadership in healthcare organizations is critical to both patient outcomes and to the success of the organization as a whole. On March 1, 2017, The Joint Commission issued a sentinel event alert on the essential role of leadership in developing a safety culture (The Joint Commission, 2017a). A sentinel event is defined as:

A patient safety event that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm and intervention required to sustain life. An event can also be considered a sentinel event even if the outcome was not death, permanent harm, severe temporary harm and intervention required to sustain life (The Joint Commission, 2017b, para 2).

Sentinel event alerts are not issued lightly or often. Since the inception of the issuance of sentinel event alerts 20 years ago, The Joint Commission has only issued 57 alerts (including this most recent alert). Examples of sentinel event alerts include alerts about preventing wrong-site surgery, safe use of opioids, preventing medication errors, preventing violence, and preventing infections. This latest alert came about as...