PURPOSE To provide criteria that defines sentinel events. To intensively analyze undesirable patterns or trends in sentinel events, and to determine where best to focus changes in the systems and processes for improvement. To comply with regulatory and accreditation standards.

POLICY

In the event of a significant undesirable performance or variation (a sentinel event), it is necessary for Medical Staffing Solutions in conjunction with the client organization to understand the causes of the event, and to make (MSS) or recommend (Client Organization) changes in the organization systems and processes to reduce the probability of such an event in the future.

DEFINITION

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 risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse overcome. The term “sentinel event” shall apply to any patient or client of Medical Staffing Solutions or a client organization.

1. Any event which has resulted in an unanticipated death or major permanent loss of function, not related to the natural cause of the patient’s illness or underlying condition (“Major permanent loss of function” means sensory, motor, physiological, or intellectual impairment not present on admission requiring continued treatment or life-style change.); or

2. The event is one of the following even if the outcome was not death or major permanent loss of function:

a) Suicide of a patient in a setting where the patient receives around-the-clock care (i.e. hospital, residential treatment center, crisis stabilization center);

b) Infant abduction or discharge to wrong family;

c) Rape (The determination of “rape” is to be based on the legal definition of the Sate of Florida)

PROCEDURES FOR REPORTING THREATS:

A. Sentinel Event Notification

1. When any event occurs that may meet the definition of a sentinel event, employees will immediately inform the Medical Staffing Solutions corporate office, his/her supervisor with the client organization and Risk Management. An incident report is to be generated and this referral is to be routed to the Medical Staffing Solutions corporate office and client organization Risk Management within 24 hours of the event.

B. Initial Screening

1. The client organization Risk Management, or in the event this does not occur, Medical Staffing Solutions Corporate Office will review the medical record. Risk Management or Medical Staffing Solutions Corporate Office will then make an initial investigation to determine if the incident falls within the definition of a Sentinel Event.

2. If the incident is not a sentinel event, the file will be closed.

C. Investigation of Facts

1. If the incident appears to meet the definition, Risk Management or Medical Staffing Solutions Corporate Office will continue its investigation, which will be completed with three (3) days with a report.

2. Upon completion of the report, the Medical Staffing Solutions President will consult and will determine if a Sentinel Event has occurred.

3. The Medical Staffing Solutions’ President will notify the hospital Administration of its determination as soon as possible.

4. Once it is determined that a Sentinel Event has occurred the President will notify the Safety Committee which is to assemble within five (5) days.

D. Safety Committee

1. The Safety Committee will convene within five (5) days to begin a Root Cause Analysis (RCA). The suggested initial schedule is:

• Orientation and review of event – by day 7
• Root Cause Analysis and Implementation – must be completed by day 45

2. At the Safety Committee initial meeting, the Committee will prepare a detailed timeline and a synopsis of the event.
E. Root Cause Analysis (RCA)

1. The focus of the RCA is to be on the process involved NOT the individuals. A framework for conducting a RCA is attached (Attachment A) and may be used to learn what went wrong and how to ensure that the event does not happen again.

2. The RCA must include:

a. determination of the human and other factors most directly associated with the Sentinel Event, and the process(es) and system(s) related to its occurrence;

b. analysis of the underlying system(s) and process(es) through a series of “Why?” questions to determine where redesign might reduce risk;

c. identification of risk points and their contributions to this type of event;

d. determination of potential improvements in process of systems that would tend to decrease the likelihood of such events in the future, or a determination, after analysis, that no such improvement opportunity exists.

e. participation by the leadership of the organization and by individuals most closely involved in the processes and systems under review.

f. internal consistentcy i.e. not contradict itself or leave obvious questions unanswered; and

g. consideration of any relevant literature.

3 An Implementation Plan will be developed and will be considered acceptable if it:

a. identifies opportunities for improvement, or formulates a rationale for not undertaking such changes; and

b. identifies who is responsible for implementation where improvement actions are planned, when the action will be implemented, and how actions will be evaluated.

4. Through the process the Safety Committee will develop findings, risk reduction strategies and implementations plans, which shall be presented to the Medical Staffing Sollutions’ President for referral to the client hospital Administration no later than the 45th day of the investigation. If prior to the completion of the RCA, the Safety Committee determines that corrective action is needed immediately, the President may implement appropriate action in areas under the control of Medical Staffing Solutions.

5. RCA is not limited to sentinel events; the Safety Committee may be convened at the discretion of risk management to investigate a hospital incident needing higher level of follow-up to address systems issues.