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Category:Risk Management Code: RM 006
Subject:Adverse and Sentinel EventsPage: 1 of 2
Policy Date:1994Revised:02/06, 09/09
Approval: ________________________ Date: ________
I.P O L I C Y
Hospice of Rutherford County investigates and documents adverse events and implements corrective action in response to adverse events.Adverse events are tracked to detect trends and plan procedure changes and employee education.The Professional Advisory Committee defines sentinel events.
Definitions:
An adverse event is an unexpected occurrence that poses risk of physical or psychological harm.
An adverse event is not primarily related to the natural course of the patient’s illness or underlying conditions.
A sentinel event is an adverse event that signals the need for immediate investigation and response.
A. The following occurrences that are the result of an adverse event and not related to the natural course of the patient’s illness or underlying conditions are sentinel events:
· Death, including suicide
· Life-threatening occurrence
· Hospitalization
B. The following occurrences are also sentinel events:
· An act of violence
· Serious injury resulting in loss of limb or function
See Policy RM 001 and Policy RM 003.
II.Procedure
1. Employees receive education regarding recognition, reporting and documentation of adverse and sentinel events at orientation and annually.
2. A root cause analysis is conducted regarding a sentinel event.The Director of Clinical Services and the Compliance Officer plan and implement the root cause analysis.
3. Results of the analysis are reported to the Executive Director, Administrative Management Team and the Medical Director.
Category:Risk Management Code: RM 006
Subject:Adverse and Sentinel EventsPage: 2 of 2
Policy Date:1994Revised:02/06; 09/09
Approval: ________________________ Date: ________
4. The Executive Director assigns responsibility for development and implementation of corrective action if determined to be necessary.
5. The Compliance Officer monitors occurrence reports regarding adverse events and sentinel events and reports findings to the Professional Advisory Committee and Performance Improvement Committee.
