New Sentinel Event Reporting System Advances Surgical Learning, Practice Improvement

In January, Joint Commission and the National Quality Forum (NQF) released a major update aligning Joint Commission’s Sentinel Event framework with the updated 2025 NQF Serious Reportable Events (SRE) list.¹ For surgeons, this alignment represents a meaningful shift in how serious adverse events are defined, reviewed, and used to guide learning.

Surgeons and the healthcare institutions in which they practice have long functioned under overlapping event-reporting frameworks—the state-mandated NQF SRE list, Joint Commission sentinel events, and internal quality systems that were not always in sync. This updated approach provides a single framework built around 28 SREs focused primarily on significant, harmful, and largely preventable patient events.

For surgeons and their teams, this new framework matters because many core surgical safety events—wrong-site surgery, retained surgical items, anesthesia-related harm, and intraoperative fires—are now defined using clear, standardized language. Events that were once described slightly differently depending on the reporting destination are now aligned under a single taxonomy, reducing confusion and administrative burden for healthcare practitioners and organizations alike.

One of the most important changes for surgeons is the expanded use of the designation “regardless of the outcome” for a limited number of procedural events. For example, wrong-site surgery and retained surgical items must be evaluated and reported—even when caught early and/or when no patient harm ultimately occurs.

This modification is not a move toward punitive oversight. Rather, it reflects a system safety approach. If a breakdown in surgical processes occurs—even one corrected before any harm takes place—it signals a vulnerability worth understanding. For surgeons, this safety mechanism reinforces the value of near-miss reporting as a professional responsibility that protects patients and strengthens team reliability.

Expanded Settings Reflect Current Surgical Settings

More than 80% of surgeries in the US are now performed in an outpatient setting,² and an increasing number of major surgical procedures (e.g., cholecystectomies, appendectomies, joint replacement surgeries) are performed using minimally invasive methods, with patients discharged the same day or after a minimal in-hospital stay.

This reality is particularly important because the surgeon frequently does not monitor and evaluate the patient on a daily basis after surgery and therefore could miss an important sentinel event. The updated SRE framework applies across all care environments, including ambulatory surgery centers, office-based procedural settings, and other locations where invasive procedures increasingly occur.

For surgeons who practice outside the hospital OR—particularly in outpatient and procedural suites—this shift ensures that safety-related expectations now travel with the procedure, not the building. The same standards for site verification, device safety, sedation monitoring, and specimen handling apply regardless of setting, creating a more consistent safety culture for surgeons and patients alike.

The revised list also includes an updated SRE related to patient harm from perioperative or periprocedural anesthesia or sedation in low-risk (American Society of Anesthesiologists [ASA] classification I–II) patients, recognizing that serious harm in these cases is often preventable when established clinical standards are followed.

For surgeons, this emphasizes shared accountability across surgical and anesthesia teams. It also reinforces the importance of role clarity, readiness to rescue, and standardized approaches to procedural sedation—particularly in settings where surgeons may work with anesthesia colleagues less frequently than in traditional OR environments.

Surgical Review Is More Consistent

Each SRE now includes detailed clinical application guidance designed to reduce ambiguity in determining whether an event qualifies as an SRE. This guidance helps reviewers distinguish between known complications and preventable system failures—a distinction surgeons value when participating in peer review and quality improvement.

For practicing surgeons, this guidance means event reviews should function in a more clinically grounded, less-subjective manner that is aligned with how surgical care actually unfolds. The focus of the review is explicitly on learning and improvement, not blame.

The new sentinel event reporting system focuses on:

Fewer reporting silos and more consistent definitions across accreditation, state, and institutional systems
Emphasis on near misses, particularly for wrong-site, wrong-procedure, and retained-item events to reveal system gaps before harm occurs
The same safety expectations for outpatient and office-based surgery, as with hospital practice
Peer-review discussions that provide clarity, are more clinically meaningful, and are supported by standardized guidance

Bottom Line for Surgeons

This new approach does not change the fundamentals of safe surgical practice; rather it aims to clarify expectations, reduce duplication, and strengthen the link between reporting and meaningful patient safety improvement. For surgeons, it represents a more coherent safety framework that aligns professional judgment with national standards, allowing them to focus less on navigating reporting systems and more on preventing harm at the bedside and in the OR.

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of Joint Commission or the ACS.

Dr. Lenworth Jacobs Jr. is a professor of surgery at the University of Connecticut in Farmington and director of the Trauma Institute at Hartford Hospital in Connecticut.