Potential improvements, called an "action plan", are identified and implemented to decrease the likelihood of such events in the future. Causal factors are analyzed, focusing on systems and processes, not individual performance. Participation is necessary by the leadership of TJC accredited healthcare organizations and by the persons closely involved in the systems under review. Main Sentinel Events reported to the Joint Commission in 2015 Type of event In addition to the list above, The Joint Commission requires each accredited organization to define sentinel events for its own care system and put into place monitoring procedures to detect these events and a procedure for root cause analysis. Radiation therapy 25% or more above the planned dose.Radiation therapy to the wrong part of the body.Receiving a blood transfusion of the wrong blood type.Suicide at a healthcare facility, or within 72 hours of departure.Objects left in a patient after surgery.Surgery mistakes (wrong body part, wrong individual).Unexpected death of an infant not born prematurely.Release of an infant to an incorrect family.They also include the following, even if death or major loss of function did not occur: Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof". The Joint Commission tracks events in a database to ensure events are adequately analyzed, and that undesirable trends or decreases in performance are caught early and mitigated. Sentinel events are identified under The Joint Commission (TJC) accreditation policies to help aid in root cause analysis and to assist in development of preventive measures. Sentinel events can be caused by major mistakes and negligence on the part of a healthcare provider, and are closely investigated by healthcare regulatory authorities. A sentinel event is "any unanticipated event in a healthcare setting that results in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness".
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