The parameters that specify when these events are reviewable seem very high; in fact, much higher than are specified by the relevant practice guidelines and regulations. Why is that?
It is important to recognize that the purpose of the Sentinel Event Policy is to promote improvement in patient safety, not to regulate practice. The parameters defining these sentinel events were intentionally selected to identify only the most extreme cases—those that should never occur. On those rare occasions when these limits are reached, it is clear that a root cause analysis is appropriate to identify the systems factors that allowed such a significant variation to occur. This is in contrast to practice guidelines and regulations that set limits on the acceptable range of practice variation.
