A sentinel event is a safety event (not primarily related to the natural course of an illness or underlying condition) that reaches an individual served and results in any of the following:

• Death

• Permanent harm (regardless of severity of harm)

• Severe harm (regardless of duration of harm)

Severe harm is critical, potentially life-threatening harm lasting for a limited time with no permanent residual, but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition.

An event is also considered sentinel if it is one of the following:

• Suicide of any individual served receiving care, treatment, or services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the organization’s emergency department.

• Abduction of any individual served receiving care, treatment, or services.

• Any elopement (that is, unauthorized departure) of an individual served from a staffed around-the-clock care setting (including the emergency department) leading to the death, permanent harm or severe temporary harm of the individual served.

• Rape, assault, or homicide of an individual served, staff member, visitor, or vendor while on site at the organization.

• Any staff-witnessed sexual contact.

• Admission by the perpetrator that sexual contact occurred on the premises.

• Unconsented sexual contact.