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
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
- Any patient death, paralysis, coma, or other major
permanent loss of function associated with a
- 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
- 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