Once a review process has been triggered for a sentinel event, the next step is to select the team members who will be responsible for conducting the RCA. (For more information on liability concerns, see "Concerns about Legal Liability," located under "Potential challenges for implementation in correctional facilities.") Stakeholders may also consider “near-misses” successful, because they can cast it as a potential error that was ultimately avoided. Reviewed events need not be the biggest or most notorious sometimes, smaller events or “near-misses” yield the most informative accounts because they have less acute liability concerns. Or they might decide that frequency of self-harm is an appropriate trigger.
Correctional settings might focus on incidents which were nearly lethal or which required significant medical intervention to save the life of a person in custody. While identifying a suicide within a correctional facility as a reviewable sentinel event may be relatively straightforward since the seriousness of death is so obvious, an important step for leadership in correctional settings will be to evaluate what incidents of self-harm should trigger an interdisciplinary review. 33 Applied to correctional settings, agencies thus have the responsibility for deciding what constitutes a sentinel event within a facility and what criteria they will use to identify reviewable events.
#A SENTINEL EVENT HOW TO#
However, it also specifies that organizations are expected to decide how to respond to patient safety events that do not meet the definition of a sentinel event but may nonetheless be worthy of review-for example a “near-miss” case. In its policy, the Joint Commission requires that accredited organizations review patient safety events that fall under their basic definition of a sentinel event (resulting in death, permanent harm, or serious temporary harm) or that fall within a list of additional events (such as suicide, unanticipated death of a full-term infant, and discharge of an infant to the wrong family). TDHB’s Serious and Sentinel Event Analysis (SSE) (carried out after these events) noted that the task was signed off as completed (as the medical officer had reviewed the ECG), even though there had been no physical review.The first step in any sentinel event review, including ones that use RCA, is defining what constitutes a sentinel event for the particular organization.
TDHB carried out a Serious and Sentinel Event Investigation Analysis (SSE) in relation to these events. The Joint Commission’s experience with its Sentinel Event Program provides us the unique perspectives we wish to share with you today. Undertake an evaluation of the impact of the interventions put in place following its Serious and Sentinel Event Analysis.
#A SENTINEL EVENT UPDATE#
Provide an update in relation to the remainder of the recommendations made in the Serious and Sentinel Event Analysis regarding what has yet to be implemented, and when this will take place - including, but not limited to, the recommendations in relation to the review of patient notes and the documentation of clinical decision- making to ensure appropriate communication.
#A SENTINEL EVENT CODE#
“Spill, Prevention, Control and Countermeasure Plan (SPCC)” Spill, Prevention, Control, and Countermeasures Plan ( SPCC Plan) means plans developed to comply with Title 40 Part 112 Oil Pollution Prevention and Health and Safety Code Division 20 Section 25270. Sentinel Events specifically include each of the following: (i) loss of life, (ii) serious injury to Court staff or Court users, (iii) physical damage or the eminent threat to the Facility resulting from fire or lightning, windstorm or hail, smoke, explosion, riot or riot attending a strike, civil commotion, aircraft or vehicle impact, vandalism, leakage or accidental discharge of water pipes of any kind, the weight of snow, ice or sleet, water damage, collapse, or sudden mechanical failure of mechanical equipment, (iv) unusual health patterns resulting from environmental contamination especially due to asbestos, mold, lead, pesticides, metals, or other agents that might be found in waste streams, in disposal sites, or other accessible locations.
The phrase, “or the risk thereof” includes any circumstance where the continuous or repeated exposure to substantially the same general conditions would carry a significant chance of a serious adverse outcome. Sentinel event means any unexpected occurrence involving death, serious psychological injury, serious property damage, or the risk thereof.
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