However, the organization is expected to prepare a root cause analysis and action plan within 45 calendar days of the event. Each accredited organization is encouraged, but not required, to report any sentinel event to The Joint Commission. 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. 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 to the wrong body region or 25% above the planned dose.Hemolytic transfusion reaction due to blood group incompatibilities.Suicide in an acute-care setting, or within 72 hours of discharge.Instrument or object left in a patient after surgery or another procedure.Surgery on the wrong individual or wrong body part. Severe neonatal jaundice (bilirubin over 30 milligrams/deciliter).Unexpected death of a full-term infant.Infant abduction, or discharge to the wrong family.Sentinel events include "unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof" and all of the following, even if the outcome was not death or major permanent loss of function:
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