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REVIEW OF SENTINEL EVENT
Sentinel Event Overview
In order to deliver best practices and design process improvements that enhance the quality of care, medical teams must have an effective reporting system. Sentinel event reporting allows medical teams to know about and understand successes and our failures.
Sentinel event review facilitates the identification of areas that the medical team will focus on for organizational learning and prevention of similar events. It is also a risk management tool that enhances the process of expedited risk control, preservation of factual information and early professional liability intervention if necessary. Identification of best practices through the review process enhances opportunities for implementation of exemplary care institution wide.
Site Medical Director (SMD) and Regional Medical Director (RMD) reviews are an opportunity to make significant contributions to improving the quality and safety of care provided by the medical team. The proposal of solutions to correct system defects will enhance care at the site where the event occurred and have potential to improve all medical care provided by the medical team. Therefore, SMDs and RMDs have ownership in ’s medical team safety record and quality improvement process. As such, there should be no fear in accurate, forthcoming and authentic sentinel event reviews that recognize how human error and system defects may have interacted to result in an event.
The goal of the sentinel event process is NOT to assign blame or take punitive measures against human error. This is not to be construed as a lack of accountability. Disciplinary measures may be taken in cases of willful, conscious disregard for policies and procedures and reckless behavioral choices. A starting place for accountability and “Just Culture” is that:
- Human error or mistakes are “consoled”
- At‐Risk Behavior is “coached”
- Reckless Behavior is “disciplined”
SMD and RMD reviews should focus on:
- Promptly identifying patient safety issues and corrective actions that address:
- Care of the affected patient (if necessary)
- Risk containment
- Preservation of factual information
- Objective and authentic retro‐ and introspective review of the care provided
- Analyzing systems and processes related to the delivery of care and the relationship to human decision‐making
- Evaluation of skills and knowledge at the site to identify educational and in‐service needs
- A culture of continuous improvement in clinical outcomes through system and process improvements aimed at decreasing preventable errors and adverse events
The RMD should further consider:
- Enhancement of the peer review process with timely feedback and “teachable moments”
- “Cascading audits”: concordance between the SMD/RMD review and Sentinel Event Committee reviews will be part of the peer review process
- Monitoring of core clinical competencies at site level
- Maintenance of governing practices related to company philosophies, policies and procedures
- Improved collaboration between regional and site leadership
- Providing support and/or debriefing for site staff who may have made mistakes which contributed to the adverse event (“second victim” management)
The SMD will review the medical record and complete the appropriate forms. The RMD will also receive a portion of the medical record (typically 30 days prior to the event) to perform an independent review in accordance with the Policies and Procedures detailed below. The RMD and SMD then discuss the sentinel event together. If regional management includes a Regional Psychiatric Director (RPD), the RMD will involve the RPD in this discussion if the sentinel event is behavioral health related. The SMD will provide the completed review forms to the HSA.
The HSA or designee is responsible for ensuring the medical records and forms are then sent to the appropriate corporate office for review by the ’s Sentinel Event Review Committee.
The Sentinel Event Review Committee is a multi‐disciplinary team that will review events and assign a final category which will lead to information transfer to the Patient Safety Committee and Risk Management as necessary.
The categorizes sentinel events for patient safety improvements as follows:
- Category 1: Identification of exemplary care
- Category 2: Indicates that health care was appropriate, following site‐specific policies and procedures.
- Category 3: Identifies potentially preventable errors of omission/commission associated with opportunities for improvement in systems/processes that were unrelated to the event.
- Category 4: Identifies potentially preventable errors of omission/commission associated with opportunities for improvement in systems/processes that were directly related to the event.
All Category 3 and 4 events should include specific areas identified that will require Corrective Action Plans (CAPs). The CAP should not just focus on individual performance, but on system and process defects that contributed to the human error. Concluding that events are attributable only to human error or lack of competence is overly simplistic, as errors are systematically connected to the environment and processes.
Human error is not an explanation for failure, but instead demands an explanation as human error is a symptom of trouble rooted inside the system. Stressing what was not done by an individual explains nothing about what actually happened and why. It is imperative to understand why actions made sense at the time and correct factors that contributed to the wrong decisions. This often requires asking questions of the staff who were directly involved with the event. These questions should be asked in a non‐threatening, open‐ended manner i.e., “Could you explain to me in your own words what happened and why?” This helps understand individual behavior by taking into account the environmental context. “Pay more attention”, “remediation”, “be more vigilant”, “try harder” has consistently been shown to retard, rather than advance the understanding of process failures. Meaningful intervention lies in the factors that contribute to error.
Corrective actions plans will be monitored for appropriateness and tracked to completion by the Patient Safety Committee. This provides an opportunity for organizational learning and a company‐wide focus on excellence.
The ’s values related to patient safety include:
- Quality: never being satisfied with the status quo, always striving to better
- Patients: treating them with dignity and compassion
- Integrity: honoring our commitment to do the right thing
- Sentinel Event reporting and review is the right thing to do. It is a framework for accomplishing the ultimate goal of improving the quality and safety of the healthcare provided by the medical team.
Sentinel Event reporting and review is the right thing to do. It is a framework for accomplishing the ultimate goal of improving the quality and safety of the healthcare provided by the medical team.
Sentinel Event Review Policies and Procedures
The purpose of the Sentinel Event Review Process is to:
- Provide information for practice and process improvements to the Patient Safety Committee, with the ultimate goal of improving the quality and safety of patient care provided by the medical team.
- Facilitate the identification of clinical liabilities for Risk Management POLICY:
A Sentinel Event is defined as an event involving death or serious physical or psychological illness/injury or risk thereof. Sentinel Events include:
- All Mortalities
- Behavioral Health Events
- All Completed Suicides
- Suicide Attempts Resulting in Hospitalization
- Non‐Suicidal Self‐Injurious (NSSI) Behavior*
*Upon request by the Behavioral Health Team on a case by case basis only
- Non‐Mortality Events
- Diabetic Ketoacidosis (DKA)
- Status Asthmaticus
- Ruptured Viscous
- MRSA Hospitalizations
- Acute Myocardial Infarction (MI)
- Medication Errors Resulting in Patient Harm
- Non‐Designated Sentinel Events, including but not limited to
- Loss of limb
- Visual or hearing impairment/loss
- Neurological impairment/Paralysis/Brain damage
- Reproductive organ impairment/loss
- Pregnancy‐related complications including ruptured ectopic pregnancies, fetal demise and any delivery on‐site
- High profile events in the media or news
- Any other events for which it may be alleged that Corizon failed to provide adequate treatment, with errors of omission/commission associated with opportunities for improvement in systems/processes
This Sentinel Event policy and procedure applies to all correctional facilities where the medical team is responsible for providing clinical services: medical, behavioral health, dental or any combination thereof. The Health Services Administrator (HSA) or designee is the ultimate responsible authority for ensuring accurate identification and reporting of events according to this policy and procedure.
The medical team will monitor for accurate reporting of events through Inpatient Census Review, Mortality Attestations, news/media monitoring and an internal reconciliation data base. How events are identified will be reviewed and reported to senior leadership. The majority of sentinel event reports should be voluntarily reported, as opposed to identification through other mechanisms.
Mortality Attestations will be sent quarterly by the medical team designee. The attestations serve as a document of verification for accrediting entities (NCCHC, ACA, etc.) that a mortality review process was completed. The ’s Sentinel Event Reviews and forms should never be distributed or shared with any non‐ third‐party in any way. Only the attestations may be shared.
The Site Medical Director (SMD) will be responsible for reviewing the event and completing a typed narrative summary and appropriate Sentinel Event Review Form. The Regional Medical Director (RMD) is also responsible for an independent review and collaboration with the SMD.
Certain sentinel events may warrant a Sentinel Event Conference Call (e.g., completed suicides, serious events that will likely be a Category 4). The purpose of a call is to gain further understanding and gather pertinent information. Calls are not meant to name, blame or shame. Calls will be set up by the medical team Designee. The call may be at the request of the site or other leadership individuals. The Sentinel Event Committee may also request a call. Call attendees may include the Patient Safety Officer, SMD, RMD, HSA, DON, Behavioral Health (when applicable), staff appropriate to the event and other invited guests as necessary. leadership reserves the right to request expedited reviews when necessary.
The site identifies a Sentinel Event.
The HSA or designee completes the Sentinel Event Notification Form which is provided to the medical team Designee within 24 hours of the event. Do not place this form in the patient’s medical record.
The HSA or designee is also responsible for notifying appropriate Regional Management within 24 hours of the event. Clients are notified according to contractual requirements; the Sentinel Event Notification Form should NOT be used for client notification or placed in the medical record.
The HSA is responsible for ensuring the integrity of the complete medical record by making a copy to secure in the HSA’s office. Original notification forms and review forms should be kept in a separate locked file. (Describe how this is done at your site)
It is the Health Services Administrator’s (HSA) or designee’s responsibility to forward the copied (can be copied from the secure copy) and collated medical records to both the SMD and the RMD along with the appropriate review forms. If an electronic medical record is used at the site, copies of documentation stored in the electronic record must be submitted. Refer to the list of requested documents that would otherwise be in the paper record. These copies should be sorted into the proper sequence with the paper portion of the record. All medical records must be collated as outlined below:
- Master Problem List
- Intake or Receiving Screening (include booking sheets, TB screen forms, ROIs, other intake related documents)
- H&P (initial or most recent annual H&P)
- All Progress Notes, Nursing Evaluations, and Infirmary Notes for 30 days prior to the event
(Chronological from first to last entry, i.e., like reading a book)
- Sick Call Requests for 30 days prior to the event (Chronological from first to last)
- Chronic Care Clinic Notes/Flow Sheets (last 2 CCC visits prior to the event, where applicable)
- Physician’s Orders (30 days prior to the event)
- MARs (current and month prior to the event)
- Laboratory and Diagnostic Studies
- Behavioral Health Notes (Chronological from first to last entry)
- Dental Notes (Chronological)
- Utilization Management (Consult requests and authorization letters)
- Hospital and other off‐site records
- Any pertinent miscellaneous documents
Any medical records not collated may be returned to the site for sorting.
For mortalities, autopsy reports should be forwarded when available. Reviews should not be delayed in lieu of autopsy results.
The SMD will review the medical records and complete the appropriate form, narrative summary and assign a category (see Sentinel Event Overview for category designations).
The RMD will perform an independent review, assign a category and then discuss the case with the SMD. The SMD should indicate the results of the collaborative discussion in the summary, then forward to the HSA.
The HSA or designee then sends the forms and medical records according to this policy to the appropriate Clinical Services corporate office (see below) within 10 business days of the event.
Upon complete submission of the chart and review forms, the Sentinel Event Committee will review and assign a final category; providing timely feedback to the SMD and RMD. The Sentinel Event Committee may request additional corrective actions.
Identified Corrective Action Plans (CAPs) must be submitted to the Patient Safety Committee and completed by site management. Completion and follow‐through of CAPs will be monitored and tracked. Incomplete CAPs will be reviewed by leadership regularly.
Sentinel Event Reviews and forms are confidential and protected by both applicable state peer review laws and in some cases attorney‐client privilege. Sentinel Event Reviews are NOT to be distributed to any agency, correctional authorities or non‐ third‐party individuals except by permission of General Counsel. During NCCHC or other audits, Mortality Attestations are acceptable to confirm that a mortality review was conducted. NCCHC or other agency auditors are not permitted to review Sentinel Events.
SMDs and RMDs should shred any copies of patient charts and/or completed forms once the HSA has secured the original copies in a locked file as defined in each site specific procedure for securing original copies.