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Never events vs. sentinel events: Assessing patient safety
Never events and sentinel events are similar types of patient safety events, but factors like prevention and reimbursement distinguish the two.
Understanding the various types of patient safety events can be difficult for healthcare professionals, especially when it comes to never events versus sentinel events.
While it might be simple to distinguish a no-harm event from other, more serious patient safety events, the differences between never events and sentinel events are murkier. Indeed, most experts consider a never event to be a type of sentinel event, with nuances about preventability and reimbursement consequences distinguishing the two.
Defining a never event
A never event is so-called because it refers to a medical error that should never happen.
The term was coined in 2001 by the National Quality Forum's (NQF) founding CEO, Ken Kizer, M.D., to describe events that, if patient safety best practices are followed, should never happen. Thus, a list of serious reportable events (SREs) was born that NQF intended for healthcare organizations to use to inform quality improvement and reporting.
The SRE list includes a range of issues or errors, including the following:
- Surgical or invasive procedure events, such as performing a procedure on the wrong patient or the wrong body part.
- Product or device events, such as the use of contaminated drugs.
- Patient protection events, such as the discharge of a newborn to the wrong family.
- Care management events, such as medication errors.
- Environmental events, such as serious injury from an electric shock during patient care or procedure.
- Radiologic events, such as the introduction of a metal object during MRI.
- Potential criminal events, such as a physical assault on a patient.
In April 2024, NQF announced plans to streamline SREs and update them to reflect today's medical landscape. Healthcare is delivered in more settings than ever before, with ambulatory care settings and telehealth seeing a surge in recent years. The updates are intended to accommodate those changes and give healthcare providers a more comprehensive view of what might constitute a never event.
Defining a sentinel event
A sentinel event is a type of never event, most experts agree.
Sentinel events refer to patient safety events that are extreme and result in "death, permanent harm, or severe temporary harm," according to the Joint Commission. They are called sentinel because they signal a need for immediate investigation and corrective action.
In 1997, the Joint Commission developed a sentinel event reporting policy intended to help healthcare organizations remediate significant patient safety issues.
"Careful investigation and analysis of Patient Safety Events (events not primarily related to the natural course of the patient's illness or underlying condition), as well as evaluation of corrective actions, is essential to reduce risk and prevent patient harm," the Joint Commission says on its website.
The Joint Commission does not require accredited organizations to report sentinel events, although it strongly encourages it. Reporting is important for transparency, and it allows the Joint Commission to help organizations investigate and remediate incidents.
Never events vs. sentinel events
As previously stated, sentinel events are a type of never event; in fact, sentinel events are often never events that have escalated.
What, then, is the distinction?
Indeed, some healthcare professionals do use never event and sentinel event interchangeably. However, there are some subtle nuances that separate them.
Foremost is the issue of preventability.
Never events are mostly considered preventable. If a healthcare organization was able to follow patient safety best practices, the never event should never occur, the NQF definition states. Conversely, a sentinel event might not be preventable or foreseeable. Still, it requires immediate response and investigation, experts say.
Additionally, never events can be tied to reimbursement models.
For example, CMS stopped reimbursing for certain never events, such as hospital-acquired infections, starting in 2008. In the 2009 inpatient prospective payment system (IPPS) final rule, CMS stated it would stop reimbursing for never events. The moves came as part of the agency's overall push to tie more reimbursement to value, CMS said.
No-harm vs. near-miss events
Although perhaps simpler to distinguish than never events and sentinel events, no-harm and near-miss events also have overlapping or related definitions.
A no-harm event is a patient safety incident that has reached but did not result in patient harm, according to the Military Health System. For example, a patient might receive the wrong blood transfusion but not have an adverse reaction because the blood was compatible.
A near-miss event is a potential medical error that has been caught before it could reach the patient, the Military Health System says on its website. In the blood transfusion example, a clinician flagging and intervening the wrong sample before it could be given to the patient would be considered a near-miss.
Although patients do not experience harm with near-miss and no-harm events, they still warrant investigation, experts say. Healthcare organizations need to assess how an error happened or could have happened.
Sara Heath has covered news related to patient engagement and health equity since 2015.
