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Sentinel Event (SE)

Date of Publication



An unexpected occurrence involving death or serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function.  The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called “sentinel” because they signal the need for immediate investigation and response.

Source of Definition

DoD Manual 6025.13: Medical Quality Assurance and Clinical Quality Management in the Military Health System (MHS)

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