Can You Identify a Sentinel Event?


Severe maternal morbidity is not always a sentinel event. Take this quiz to test your understanding of what constitutes an obstetric sentinel event.

In January 2015, the Joint Commission announced a revised definition of a sentinel event. The revised definition is any patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in death, permanent harm, or severe temporary harm.

Severe maternal morbidity-a patient safety event that occurs intrapartum through the immediate postpartum period (24 hours) that requires the transfusion of 4 or more units of RBCs (previously defined as blood products, such as fresh frozen plasma, packed red blood cells, whole blood, platelets) and/or admission to the ICU-is considered a sentinel event, but only if the event is not an expected result of the patient's condition.

To help obstetric providers better understand these changes, the Council on Patient Safety in Women’s Health Care, supplied the case vignettes featured in this quiz as examples of what would and would not constitute a sentinel event during a webinar held January 29, 2015. 

For more information, see Sentinel Events and Severe Maternal Morbidity.

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