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. Main Sentinel Events reported to the Joint Commission in 2015 Type of event 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 25% or more above the planned dose.Radiation therapy to the wrong part of the body.Receiving a blood transfusion of the wrong blood type.
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