Description:
A Sentinel Event is defined by The
Joint Commission as “any unanticipated event in a
healthcare setting resulting in death or serious
physical or psychological injury to a patient or
patients, not related to the natural course of the
patient’s illness." Sentinel Events include:
- Alleged sexual assult or complaint of
nonconsexual sexual activity.
-
Sexual violation of a non-consenting or incompetent adult,
including sexual activity considered inappropriate
because of circumstances, situation or environment,
which infringes on a person’s freedom or rights or
involves high risk of disease transmission.
- Elopement, escape or period in which a client is missing from
a restricted living unit or supervised/escorted activity
or unsupervised furlough/visit/pass.
- Incident involving a client that occurs in the community, such
as an arrest, crime or conflictive situation with
another person(s) that could potentially result in a
negative outcome or media attention.
- Death of a client that occurs while in the care or residence
of a Liberty program/service or death that occurs within
seven days of discharge from a Liberty program/service,
which may be attributed to an unusual occurrence,
accidental or unnatural cause, “unattended” status, or
procedural/treatment error.
- Threats or acts of violence, such as bomb threats, arson,
abduction,or the use of
weapons and/or toxic chemical agents.
- Homicide or credible suicide attempt occurring within the
program/service.
- Confirmed/substantiated allegations of client physical abuse,
gross neglect or exploitation. Significant incidents affecting the life and safety of a
patient that appear highly unusual for the
program/setting. Legal issues and/or events that could result in possible
litigation (e.g. lawsuits filed by a client that could
bring media attention).
- Felonious behavior (e.g., production/sale/distribution of
illegal drugs, murder, manslaughter, rape) or
significant illicit behavior involving staff or clients
that could adversely impact the reputation of the
organization. Five or more falls or accidents of a client within a one year
period resulting in injury.
- Serious injury (e.g., wounds requiring more than three
sutures/staples to close, concussions, fractures,
dislocations, or injury which, in the opinion of the
Physician, may result in permanent disability,
impairment, or disfiguration) of a client or employee
requiring treatment by a Physician.
- Any loss or destruction of facility property with a
replacement cost of $500 or more.
Reporting Instructions:
- If you are not the manager or program director, you need to contact your immediate supervisor to verbally report the incident immediately.
- If you are the designated reporting individual for this event, complete the
Sentinel Event Form
attached to this link. This form will serve as the initial reporting form for Sentinel Events.
- Send the completed form attached to a secured Liberty email to
sentinelreport@libertyhealth.com within 24 hours of the incident.
- You will need to consult with the Vice President, Performance to complete the investigation and root cause analysis (if appropriate). You may consult the Liberty SOP
Sentinel Event for additional guidance and information.
Additional Manager Reporting Instructions:
- If an investigation is required or recommended, complete the Investigation Report
Form, and send within 10 calendar days to Vice President, Performance (sentinelreport@libertyhealth.com).
-
If the investigation results in a corrective
action plan or recommendations for changes,
complete the
Follow Up Report
within 90 days of event and send to Robin Burkert, Vice President, Performance.
(sentinelreport@libertyhealth.com).
Incident Reporting Policy
Back to "Types of Reportable Incidents" list
Download PDF Incident Reporting Form
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