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In issuing new patient safety standards, the Joint Commission included the following definitions:
An unintended act, either of omission or commission, or an act that does not achieve its intended outcome.
An unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
Used to describe any process variation that did not affect the outcome, but for which a recurrence carries a significant chance of a serious adverse outcome. Such a near miss falls within the scope of the definition of a sentinel event, but outside the scope of those sentinel events that are subject to review by the Joint Commission under its sentinel event policy.
Any set of circumstances (exclusive of the disease or condition for which the patient is being treated), which significantly increases the likelihood of a serious adverse outcome.
Source: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL.