Sentinel Event/Adverse Incident

If a sentinel event should occur in this facility, the 
following reporting process will be followed:
Department of Health and the Department of Regulations for 
the State of New York.
The agency accrediting this facility will also be notified 
and other voluntary reporting is encouraged by leadership.
The broad definition of a sentinel event is as follows: A 
sentinel event is an unexpected occurrence involving death or 
serious physical or psychological injury, or the risk 
thereof.  Serious injury specifically includes loss of limb 
or function.  The phrase, 'or the risk thereof' includes any 
process variation for which a recurrence would carry a 
significant chance of a serious adverse outcome.
Such events are called 'sentinel' because they signal the 
need for immediate investigation and response.
A root cause analysis will be conducted to determine cause of 
sentinel or adverse event.
The definition of a root cause analysis is as follows:  Root 
cause analysis is a process for identifying the basic or 
causal factors that underlie variation in performance, 
including the occurrence or possible occurrence of a sentinel 
event. A root cause analysis focuses primarily on systems and 
processes, not individual performance. It progresses from 
special causes in clinical processes to common causes in 
organizational processes and identifies potential 
improvements in processes or systems that would tend to 
decrease the likelihood of such events in the future, or 

determines, after analysis, that no such improvement 
opportunities exist.
The product of the root cause analysis is an action plan that 
identifies the strategies that the organization intends to 
implement to reduce the risk of similar events occurring in 
the future. The plan should address responsibility for 
implementation, oversight, testing as appropriate, time 
lines, and strategies for measuring the effectiveness of the 
actions. This plan is communicated to all appropriate staff.
Staff – All individuals involved in a sentinel or adverse 
event will be given appropriate support; without judgments 
with the focus on the entire process revolving around such an 
event rather than blaming an individual. 
Annually or more frequently if needed governance receives a 
written report on any adverse or sentinel events; including 
whether patients or families were informed, and actions taken 
to improve safety. 
The following are considered sentinel events in this 
organization; whether deemed reportable or not and if there 
is an occurrence; a root cause analysis will be conducted:
    -   Unexpected occurrence involving patient death or 
        serious physical or psychological injury or illness, 
        including loss of limb or function, not related to 
        the natural course of the patient's illness or
    -   Any infection resulting in the loss of a limb, use
        of a limb, permanently affects a patient's quality
        of life or results in death shall be investigated 

      as a sentinel/adverse event.
    -   Any variation in process which carries a significant 
        chance of a serious adverse outcome. E.g. drug error 
        (not reportable)
    -   Any patient death, paralysis, coma, or other major
        permanent loss of function associated with a 
        medication error
    -   Injury caused by defective equipment
    -   Surgery on the wrong patient, wrong body part, or 
        wrong side of the patient's body regardless of the 
        magnitude of the procedure or the outcome
    -   Assault, homicide, or other crime resulting in 
        patient death or major permanent loss of function.
    -   A patient fall that results in death or major 
        permanent loss of function as a direct result of the 
        injuries sustained in the fall.
    -   Transfer to another level of care will be evaluated 
        by the Medical Director as to pertinence for 
        Sentinel event
    -    Unintended retention of a foreign object in an 
        individual after surgery or other procedure.
    -   Breaches in medical care, administrative procedures 
        or other breeches that result in a negative impact 
        on a patient, even where death or loss of limb or 
        function does not occur.
    -   Medication errors, including errors that occur due 
        to failure to reconcile medications.(not reportable)
    -   Tubing and catheter misconnection errors 
    -   Adverse event related to a power outage 
    -   Any violence in the workplace either from, to, or
        between patients, staff, families or visitors
The event is one of the following (even if the outcome was 
not death or major permanent loss of function unrelated to 
the natural course of the patient's illness or underlying 
Abduction of any individual receiving care, treatment or 
services. During the Hazard Vulnerability study the 
probability was assessed at 1 therefore it is not considered 
applicable to this organization.

Approved By Governing Board    
Control #301.14